Camden in the News
November 16, 2011
Personal Best: Top athletes and singers have coaches. Should you?
The New Yorker
Atul GawandeThe sort of coaching that fosters effective innovation and judgment, not merely the replication of technique, may not be so easy to cultivate. Yet modern society increasingly depends on ordinary people taking responsibility for doing extraordinary things: operating inside people?s bodies, teaching eighth graders algebraic concepts that Euclid would have struggled with, building a highway through a mountain, constructing a wireless computer network across a state, running a factory, reducing a city?s crime rate. In the absence of guidance, how many people can do such complex tasks at the level we require? With a diploma, a few will achieve sustained mastery; with a good coach, many could. We treat guidance for professionals as a luxury?you can guess what gets cut first when school-district budgets are slashed. But coaching may prove essential to the success of modern society. There was a moment in sports when employing a coach was unimaginable?and then came a time when not doing so was unimaginable. We care about results in sports, and if we care half as much about results in schools and in hospitals we may reach the same conclusion. Local health systems may need to go the way of the Albemarle school district. We could create coaching programs not only for surgeons but for other doctors, too?internists aiming to sharpen their diagnostic skills, cardiologists aiming to improve their heart-attack outcomes, and all of us who have to figure out ways to use our resources more efficiently. In the past year, I?ve thought nothing of asking my hospital to spend some hundred thousand dollars to upgrade the surgical equipment I use, in the vague hope of giving me finer precision and reducing complications. Avoiding just one major complication saves, on average, fourteen thousand dollars in medical costs?not to mention harm to a human being. So it seems worth it. But the three or four hours I?ve spent with Osteen each month have almost certainly added more to my capabilities than any of this. Talk about medical progress, and people think about technology. We await every new cancer drug as if it will be our salvation. We dream of personalized genomics, vaccines against heart disease, and the unfathomed efficiencies from information technology. I would never deny the potential value of such breakthroughs. My teen-age son was spared high-risk aortic surgery a couple of years ago by a brief stent procedure that didn?t exist when he was born. But the capabilities of doctors matter every bit as much as the technology. This is true of all professions. What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities. A determined effort to introduce coaching could change this. Making sure that the benefits exceed the cost will take work, to be sure. So will finding coaches?though, with the growing pool of retirees, we may already have a ready reserve of accumulated experience and know-how. The greatest difficulty, though, may simply be a profession?s willingness to accept the idea. The prospect of coaching forces awkward questions about how we regard failure. I thought about this after another case of mine that Bob Osteen came to observe. It didn?t go so well. The patient was a woman with a large tumor in the adrenal gland atop her right kidney, and I had decided to remove it using a laparoscope. Some surgeons might have questioned this decision. When adrenal tumors get to be a certain size, they can?t be removed laparoscopically?you have to do a traditional, open operation and get your hands inside. I persisted, though, and soon had cause for regret. Working my way around this tumor with a ten-millimetre camera on the end of a foot-and-a-half-long wand was like trying to find my way around a mountain with a penlight. I continued with my folly too long, and caused bleeding in a blind spot. The team had to give her a blood transfusion while I opened her belly wide and did the traditional operation. Osteen watched, silent and blank-faced the entire time, taking notes. My cheeks burned; I was mortified. I wished I?d never asked him along. I tried to be rational about the situation?the patient did fine. But I had let Osteen see my judgment fail; I?d let him see that I may not be who I want to be. This is why it will never be easy to submit to coaching, especially for those who are well along in their career. I?m ostensibly an expert. I?d finished long ago with the days of being tested and observed. I am supposed to be past needing such things. Why should I expose myself to scrutiny and fault-finding? I have spoken to other surgeons about the idea. ?Oh, I can think of a few people who could use some coaching? has been a common reaction. Not many say, ?Man, could I use a coach!? Once, I wouldn?t have, either. Osteen and I sat together after the operation and broke the case down, weighing the decisions I?d made at various points. He focussed on what I thought went well and what I thought didn?t. He wasn?t sure what I ought to have done differently, he said. But he asked me to think harder about the anatomy of the attachments holding the tumor in. ?You seemed to have trouble keeping the tissue on tension,? he said. He was right. You can?t free a tumor unless you can lift and hold taut the tissue planes you need to dissect through. Early on, when it had become apparent that I couldn?t see the planes clearly, I could have switched to the open procedure before my poking around caused bleeding. Thinking back, however, I also realized that there was another maneuver I could have tried that might have let me hold the key attachments on tension, and maybe even freed the tumor. ?Most surgery is done in your head,? Osteen likes to say. Your performance is not determined by where you stand or where your elbow goes. It?s determined by where you decide to stand, where you decide to put your elbow. I knew that he could drive me to make smarter decisions, but that afternoon I recognized the price: exposure. For society, too, there are uncomfortable difficulties: we may not be ready to accept?or pay for?a cadre of people who identify the flaws in the professionals upon whom we rely, and yet hold in confidence what they see. Coaching done well may be the most effective intervention designed for human performance. Yet the allegiance of coaches is to the people they work with; their success depends on it. And the existence of a coach requires an acknowledgment that even expert practitioners have significant room for improvement. Are we ready to confront this fact when we?re in their care? ?Who?s that?? a patient asked me as she awaited anesthesia and noticed Osteen standing off to the side of the operating room, notebook in hand. I was flummoxed for a moment. He wasn?t a student or a visiting professor. Calling him ?an observer? didn?t sound quite right, either. ?He?s a colleague,? I said. ?I asked him along to observe and see if he saw things I could improve.? The patient gave me a look that was somewhere between puzzlement and alarm. ?He?s like a coach,? I finally said. She did not seem reassured.