Category Archives: Uncategorized

Physician Coaching, An Evidence-based Tool for Resident Wellness

  • Tonya L. Caylor, MD, FAAFP
  • tlcaylor@mac.com
  • Clinical Associate Faculty, On-call Faculty for Alaska Family Medicine Residency
  • Joy in Family Medicine Coaching Services®

Physician coaching, a key tool for preventing and addressing burnout, is being incorporated into residency and fellowship training programs. Professional coaching has been around for decades for leaders in fortune 500 companies. It turns out, that it translates well to medicine and impacts burnout. In August of 2019, JAMA published an article telling of the benefits of physician coaching: it decreases emotional exhaustion and burnout out while increasing resilience and quality of life.1  Other studies show similar results. 2,4

For those unfamiliar with professional coaching, it’s good to start with a definition of what it is and isn’t. First, coaches are not mentors; mentors are those looked up to and emulated. Coaches are not advisors; advisors guide, direct and give advice.  Coaches are not therapists. Therapists diagnose and treat those with DSMV mental health conditions. Coaching officially defined as partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential. Foundational to coaching is that the client is seen as whole, capable, and resourceful. Most academic medicine coaches use a causal-coaching approach rooted in positive cognitive psychology.

After my own personal burnout period, I discovered coaching. I grew tremendously. I was so convinced that these principles and approaches were critical for everyone, including those I’m most dedicated to – resident physicians. I began my coaching journey in the Fall 2019, took courses, became certified, and started my business in 2020. I have had the privilege of coaching high-functioning residents that want to grow into their goals as well as some who are struggling in one area or another. The outcomes are the similar. They uncover limiting beliefs, learn tools to navigate life and career, decrease unnecessary suffering, improve their outlook, and move toward the future they envision. Physicians who are trained coaches have the unique advantage of understanding issues that augment relating to the client. It is worth pointing out, that residents need a safe space, so using non-evaluative physician coaches is crucial.  

I performed pre- and post-course surveys with the Maslach Burnout Index and a linear quality of life scale for quality improvement to residents and recent graduates who went through my 6 session 1:1 coaching plus program. Eighty percent of those participating met burnout criteria at the beginning of the course, compared to only 40% who completed the program after the conclusion. Even the remaining 40% had significant improvement in emotional exhaustion, depersonalization, and personal accomplishment scores. 80% reported improved quality of life (none showed a decrease). All reported subjective positive feedback. Each 1:1 participant completed the course if they paid (with or without program support for time) and even if they didn’t pay (scholarship or program paid) but the program carved out time for them – one hour a week for 6 weeks. 

Coaching resident physicians is not only helpful for the individual, but the program as well. They have a different approach to their colleagues, staff, and attendings. An example – during a coaching session, a resident felt a particular attending was “against him.” We parsed out fact from thoughts. He was then open to giving the attending the benefit of the doubt. He had less rumination, less unnecessary suffering, and engaged with the attending in a healthier manner. Another program I had the honor of coaching, enrolled faculty and residents in a series of separate group sessions. They now share a common language and toolbox that improve the program’s culture. The program ran pre- and post- course surveys and are in the process of analyzing the data. 

Various methods to access coaching for residency and fellowship programs are being trialed, including one-on-one coaching, group coaching, and hybrid models, both with and without mini curricular topics, and some offer CME. Some institutions, such as Harvard4, explored basic coach training with their faculty to coach trainees outside their primary discipline. Others, such as Stanford, contract with an outside physician coach annually for their anesthesia fellows.  

Funding sources vary. In the Mass General study3, there were grants, and volunteer hours. In the Penn State study5 there was a designated FTE budget utilized. Various wellness funds, CME/book funds, HSA dollars, scholarships, and individual self-funding have all been used. New physician coaches often donate hours to get experience. (A list of coaches known to me with experience in academic coaching at various levels are listed in the table.)

I encourage all residency and fellowship programs to consider incorporating coaching into their wellness and remediation structure as the next step in supporting trainees and faculty, improving the culture of medicine, and preserving a healthy workforce that enjoy their chosen career.  

Table 1

Coaches/ProgramsLead CoachWebsiteEmailClient focus
Empowering Women PhysiciansSunny Smith, MD FAAFPempoweringwomenphysicians.comsunny@empoweringwomenphysicians.comClients: women physicians including all levels of academics
Joy in Family Medicine Coaching Services®*Tonya Caylor, MD FAAFPhttp://www.joyinfamilymedicine.comjoyinfamilymedicine@gmail.comClients: Family Medicine residents, faculty, and recent graduates
LadyDOxCorinna Muller, MD FACOOGhttp://www.ladydox.comdr_m@ladydox.comClients: women physicians including all levels of academics, not limited to DO’s
Pause and Presence CoachingJessie Mahoney, MDwww.jessiemahoneymd.comjessie@jessiemahoneymd.comClients: All including residents and fellows
The Institute for Physician WellnessKathy Stepien, MDhttp://www.instituteforphysicianwellness.comkathy@instituteforphysicianwellness.comClients: all physicians, including all level of academics
This Osteopathic Life Amelia Bueche, DOhttp://www.thisosteopathiclife.comthisosteopathiclife@gmail.comClients: all physicians, including all levels of academics, not limited to DO’s
*disclosure – the author has a financial relationship with the program that has an asterisk

References

  1. Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians: A Pilot Randomized Clinical Trial [published online ahead of print, 2019 Aug 5]. JAMA Intern Med. 2019;179(10):1406-1414. doi:10.1001/jamainternmed.2019.2425
  2. McGonagle AK, Schwab L, Yahanda N, et al. Coaching for primary care physician well-being: A randomized trial and follow-up analysis [published online ahead of print, 2020 Apr 16]. J Occup Health Psychol. 2020;10.1037/ocp0000180. doi:10.1037/ocp0000180
  3. Palamara, Kerri et al. “Promoting Success: A Professional Development Coaching Program for Interns in Medicine.” Journal of graduate medical education vol. 7,4 (2015): 630-7. doi:10.4300/JGME-D-14-00791.1
  4. Palamara K, Kauffman, C, et al. Professional Development Coaching for Residents: Results of a 3-Year Positive Psychology Coaching Intervention [published online ahead of print, 2018 Jul 23]. J Gen Intern Med. 2018;33(11):1842-1844. 
  5. Jed D. Gonzalo, Daniel R. Wolpaw, Karen L. Krok, Michael P. Pfeiffer & Jennifer S. McCall-Hosenfeld (2019) A Developmental Approach to Internal Medicine Residency Education: Lessons Learned from the Design and Implementation of a Novel Longitudinal Coaching Program, Medical Education Online, 24:1, DOI: 10.1080/10872981.2019.1591256

What’s in a Title? Establishing Clear Expectations and Professional Culture Through How We Address Our Colleagues.

What’s in a Title? Establishing Clear Expectations and Professional Culture Through How We Address Our Colleagues

Kelly M. Roberts, PhD, LMFT; P.K. Grafton, DO; Jaspreet Kaur, DO

“Bye, Doctor [male intern last name]. Bye, [female resident first name],” said the male attending physician as the residents left the continuity clinic.

“What’s in a name?” wondered the female resident, having been casually addressed with her first name multiple times, in comparison to colleagues addressed with their professional titles. 

This interaction, however, was particularly unsettling for her and raised multiple internalized questions. Was this the attending’s attempt to encourage the intern to use his newly earned title and foster professional development, or was this an attempt to demean her? Was it intentional or unintentional? Conscious or subconscious? Did the matter warrant further attention and discussion? Would failure to contend with the issue affect her performance or growth?

This wasn’t the first instance of title imbalance; multiple versions of this same scenario had been raised by residents over the course of two years, yet our program wasn’t realizing lasting change. Meetings were held based upon this particular instance, and since that time everyone involved has reflected on multidimensional aspects related to title utilization.

As a debriefing exercise, we are sharing combined administrator and resident perspectives covering a few title utilization conceptual areas such as identity formation, power differentials, programmatic culture, and clarity of expectations

Identity Formation

Becoming a physician involves more than acquiring medical knowledge and developing clinical skills. Physicians also need to develop professional identities—physician, community leader, medical board member, etc. These identities start long before medical school but must be cultivated during school, residency, fellowships, and throughout attending practice. Students and residents establish evolve their identities through social experiences, patient encounters, and educational time spent with attending physicians and mentors. Helping students and residents form their professional identities, and function appropriately within them, is a critical component of the medical education system. The title of “doctor” is one that a student will need guidance and education growing into and maintaining.

Power Differentials and Hierarchies

Physician burnout and well-being is a current hot topic. Many studies discuss the use of Maslow’s hierarchy of human needs as the potential framework for addressing wellness. Part of this hierarchy is esteem. A physician’s esteem is tied to multiple internal and external factors. Especially during residency training, external factors play a large role in physician esteem. After working through undergraduate, medical school, and then additional years of residency, achieving the title “doctor” has significant and powerful meaning. Hearing patients, attendings, and nurses refer to you as “doctor X” is empowering. While on the flip side, being addressed without your title by a superior can leave you questioning their respect and opinion of you as a physician.

Professional Culture

Residents are encouraged to use their titles in lieu of first name when introducing themselves to patients or nurses at most training programs. The formality of titles is generally lax when residents are amongst their colleagues in resident work areas, call rooms, and table rounds. However, the title strategically finds its place during bedside rounds, a formal setting involving patient care. Deciphering between the appropriate use and setting for casual versus formal communication is foundational in building trust and respect, and is unique to training programs. A 2017 study examined the likelihood of professional titles usage during introductions at internal medicine grand rounds and found females introduced male speakers with formal titles 95% of the time in comparison to 49% male introducing female speakers. Female introducers in general were more likely to use professional titles when introducing any gender speaker in comparison to male introducers.

Clarity of Expectations

The possibly unintentional variation in formality may undermine the expertise of female physicians and impact their professional growth. In a training environment, it is imperative to follow a unified, though not necessarily formalized process for addressing resident physicians—male and female—as they advance in their professional roles. Establishing the appropriateness of casual versus formal communication is unique to institutions given its multifactorial nature; although universally clarifying expectations could enhance sensitivity and potentially mitigate existing gender bias in medicine.

Our Own Process

One exercise that assisted with defining a few of these elements was the decision to deploy an STFM CONNECT post over this topic. The following quotes pulled from that post demonstrate the diversity of perspectives offered at the time:

…Lopsided use of titles is arrogant to my ear. My ego and confidence as a physician are not wrapped up in a title.

…This is something that physicians in a larger community, such as where I practice now, rarely have to consider.  But in small towns, physicians interact with their staff and their patients in a host of very close ways that would be quite avoidable – and even considered of questionable ethics – in regions of higher population density.  The use of the title allows us to take a step back and be more “objective” while continuing to address health issues of those for whom we care (care, in every sense of the word).

…I call residents “Doctor” so the patients, nurses, others, and they themselves know who they are and their role, especially important for URM and women. They are not expected to be the patient’s friend, nurse, pal, aide, etc. They are expected to be each patient’s physician.

Attendings hold immeasurable power to propitiate, or stunt, resident growth on a daily basis. As members of STFM, externalizing your own questions will undoubtedly prevent residents from internalized struggles about their own identity, helping them own, with all the rights and responsibilities, the true and noble title of doctor.

Unconscious Bias and Lower Expectations

By Christina Johnson MD, PhD

Christina Johnson MD, PhD
Clinical Faculty, Overlook Family Medicine

I remember how excited we felt about starting college. At the minority prefreshman program, we met with the new director of multicultural student services and the new African-American chaplain, who were both deeply interested in our success. This is because we were the largest class of Black and Hispanic students the school had ever seen. We had all grown up in the hip hop 1980’s, but we also represented the last cultural vestiges of the 1960’s and 1970’s. Most of us were active members of student committees and groups that promoted cultural pride and educational success. We had watched Eyes on the Prize in school or with our parents and understood the significance of struggle. We knew the Fresh Prince, Parliament Funkadelic and Nirvana. Our experiences ranged from public schools to exclusive boarding schools. We felt that we were culturally ready for college.

The problem was that the school had not yet been prepared for us. We sat one day in the Unity House meeting room with several deans and administrators who were deeply concerned. They heard that many of us intended to go into health careers. They welcomed us to the campus and told us that we should feel at home. Then they encouraged us to consider other careers, because it was not likely that we would make it into medical school (the odds were so low), and it would be more realistic to consider other options. This is before any of us wrote a paper, fretted over a chemistry calculation, or dissected a frog. We understood that they were well intentioned. What they meant was that there was unlimited potential for growth and learning in college and that we should be open to the possibilities of exploring all our interests. What they didn’t know was that we had met them before. 

I met them when I sat in front of a panel for a scholarship interview, and they expressed their surprise at my great scores—for a minority, public school student. I would meet them again while arriving for a research training program at the National Institutes of Health and being mistaken as the new secretary. Then again, when interviewing for medical school with a medical director who thought I must be interested in the MD/PhD program only because of the money involved—surely my interests weren’t purely academic. They were the same professors who encouraged me to consider traveling around Europe to “find myself” when I told them I was interested in medicine. These were gatekeepers to the realm of academic possibilities, and they knew that we were unlikely to succeed.

What they did not realize was that I had prayed about what I was supposed to do in life, having been urged to decide by the ever-looming threat of preteen pregnancy and the dropout rates in my neighborhood. I made the decision to become a doctor when I was 12 years old, and it was then that I decided I belonged to that community. The concurrent presence of negative voices along my journey did not dissuade me, but they affirmed my belonging to the shared struggle experienced by my family, friends, and community in pursuing our collective dreams. Their attempt to advise us to make decisions based on our putative limitations were already a part of our lived experience. It is true that during college many of us found our niche in other fields. However, those decisions arose freely as a part of the normal exploration of interest and identity that occurs in the college environment. Indeed, many of us did become medical professionals.

Much of my journey to becoming a physician and a researcher has been marked by academic curiosity and perseverance, incredible mentorship, and family support.  Medicine is where my community focus and intellectual fervor align. However, it is the thread of rejection that has been a constant motivator. It is the reason why I am not just a clinician, but a community educator, an advocate, and a mentor. It has allowed me to see belonging to this community as both an earned privilege and a gateway for others to adopt a posture of belonging as they pursue their goals.