Graduating With Honors in Resilience: Creating a Whole New Doctor

Abstract

Background

Although coaching programs have become a prominent piece of graduate medical education, they have yet to become an integral part of undergraduate medical education. A handful of medical schools have utilized longitudinal coaching experiences as a method for professional identity formation, developing emotional intelligence and leadership.

Objective

We developed A Whole New Doctor (AWND), a medical student leadership development and coaching program at Georgetown University, with the aim of fostering resilience, leadership, and emotional intelligence at the nascent stage of physician training. To our knowledge, ours is the only program that is largely student-managed and uses certified executive coaches in the medical student population.

Methods

Cohort 1 of AWND started in October 2016. For each cohort, we hold a kickoff workshop that is highly interactive, fast-paced and covers coaching, complex thinking, reflective writing, and a coaching panel for Q&A. Following the workshop, students work with coaches individually to address self-identified weaknesses, tensions, and areas of conflict. We believe the program’s student-driven nature provides a new structural approach to professional development and leadership programs, offering students a simultaneously reflective and growth-oriented opportunity to develop essential non-technical skills for physician leaders.

Results

Of the 132 students in the program, 107 have worked with one of our coaches (81%). Student testimonials have been uniformly positive with students remarking on an increased sense of presence, improvements in communication, and more specific direction in their careers.

Conclusion

Our pilot coaching program has received positive feedback from students early in their medical training. It will be important to further scale the program to reach an increasing number of students and quantitatively evaluate participants for the long-term effects of our interventions.

Introduction

Physician burnout – a syndrome characterized by depersonalization, emotional exhaustion, and the sense of low personal accomplishment – is well-documented in the literature. ¹ Despite the inherent meaning in their work, one-third to one-half of physicians meet criteria for burnout as measured by the Maslach Burnout Inventory. ¹ Research demonstrates that these symptoms often precede full-time employment, however, and begin in the nascent stages of a physician’s career during their medical training. Most concerning, of the many medical students screening positive for depression and symptoms of burnout, only 15.7% reported seeking treatment.^2,3 Given the alarming statistics, Karp and Levine recently published an urgent call for all medical schools to assemble dedicated medical student mental health care teams as they had done at the University of Pittsburgh School of Medicine. ⁴

These problems are important not only for physicians, but for their patients as well. Accumulating evidence demonstrates that physicians’ self-reported satisfaction is linked to patient satisfaction ⁵ and vice versa, with physician burnout linked to lower patient satisfaction, longer post-discharge recovery times, ⁶ and increases in medical errors.^7,8

Wellness, Practice Efficiency and Resilience

While the etiology of burnout is multifactorial, three domains have been suggested as key: culture of wellness, efficiency of practice, and personal resilience. ⁹ The former two of these domains exist at the systems level, but it is the last, personal resilience, that is the focus of our approach. This is not to discount systemic changes that begin with the individual. It is certainly plausible that satisfied individuals may promote a culture of wellness through encouraging positive health behaviors in their colleagues and patients.

Coaching—What’s That? (Hint: It’s Different From Mentoring)

Coaching, as defined by the International Coach Federation, is “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.” Coaching for medical students is similar to coaching in most other endeavors. A coach works with a student to continually improve his/her performance, usually on areas that the student deems weak. By asking powerful questions and creating a space to reflect on the tensions in medical education, coaches give students the opportunity to assess and improve their emotional intelligence, durability, wellbeing, and resilience.

The difficulties medical students struggle with are multifaceted, including excessive workload, difficulty with studying and time management, conflicts in work-life balance and relationships, health concerns, and financial stressors. ¹⁰ In addition, these stressors are dynamic, changing as students proceed through their training. For instance, whereas first-year students more consistently struggle with workload, third-year students more consistently struggle with work-life balance as they transition onto the hospital wards. ¹⁰ We chose coaching as our primary intervention, as it is a highly individualized process that aims to meet students where they are in their challenges, and provide a constructive dialogue on reworking, reframing, or overcoming that challenge.

Given the scarcity of leadership training and professional coaching in medical training, we thought that by going upstream, to medical students, the effects would multiply as they moved into their residencies, fellowships, and clinical practices. Frequently, the behaviors and perspectives physicians bring to their careers first formed during medical school. While professional coaching may be effective in reducing burnout and promoting wellbeing in practicing physicians, ¹¹ our focus is on students to implement productive and resilient mindsets from the start, rather than undoing counterproductive and labile ones later.

While the number of coaching programs continues to increase throughout U.S. medical schools, to our knowledge, our program, A Whole New Doctor, is the first and only medical student coaching program that uses certified executive coaches to address the aforementioned issues of burnout and personal resilience. These professional coaches are integral to our program because their aim is not to give advice or provide networks for professional career development, but rather to communicate sincerely and effectively with students. They do so by asking powerful questions such that students can begin to introspect and solve or reframe their own challenges. It is a pathway to personal development by those trained in effective communication and with a sense of objectivity and inquisitiveness towards the field of medicine, as opposed to those already in the system.

Methods

Seven cohorts, consisting of approximately 20 students each, have participated and are participating in our A Whole New Doctor program. Twice a year – once in the spring and once in the fall – a workshop is held with a focus on leadership, reflection, and most importantly, an introduction to coaching for medical students. The workshop runs for a full day and is meant to acclimate students to coaching concepts and strategies such as navigating polarities in medicine (e.g., balancing interpersonal skills with medical-knowledge competency), active listening, and goal-setting. Students across all four years of medical school submit an application to attend the workshop, which, upon completion, inducts them into the A Whole New Doctor community.

In the months following the workshop, students have the opportunity to participate in six one-hour coaching sessions. Students and coaches have autonomy over these sessions, which are independently scheduled by the participants. The sessions are self-directed from the beginning, as students not only choose their coaches, but also the topics they would like to discuss and address with their coaches. This design is intentional, as coaching reminds students of their capacity to shape their own experiences in medical school with their values and goals. For example, one student may want to focus on study strategies and time management, while another may want to improve his/her non-verbal communication and listening skills. This approach both empowers students to take ownership of their education in addition to allowing for internal motivators in contrast to external motivators, i.e., tests, grades. ¹²

Professional Coaches

In addition to interested and engaged students, coaches form the second critical component of our program. We have 39 coaches, many of whom have previously worked with medical professionals, and some who have not. The coaches are all professionally trained with years of experience. To our knowledge, they differ from coaches at other medical schools by two distinct traits. First, they are not from the roster of clinical faculty members – they are members from the coaching community who generously volunteer their time. This component is important for an environment of emotional safety and non-judgment. Even amongst your most trusted attendings, the power dynamics in medical education can make it hard to open up. Second, our coaches have been professionally trained with a heightened skill set. Coaching training involves 60 hours of coach-specific training and 100 hours of coaching just for the entry-level credential. ¹³ As in learning medicine, becoming a coach requires book learning, practice, feedback, and more practice as coaches move from a linear way of thinking to one that embraces complexity and teaches them how and when to ask powerful questions. It requires high-quality listening and staying focused on the speaker. In this way, students not only grow through constant goal-setting and feedback, but also through engagement with an expert in communication.

Coaching Promotes Resilience and Self-Identity

The relationship that grows between the student and the coach is meant to be the foundation that promotes resilience and self-identity. A practice of self-reflection is necessary for the student to even begin a conversation with the coach. By putting feelings into words, students begin to define an inherent tension they feel. The coach then guides the student to either address the troublesome situation, or when this is not possible, to reframe the situation. This practice is integral to patient-centered care, as students early in their training practice skills of mindful presence and awareness that is integral to forming trust and rapport with diverse patient populations. The process also allows students to process the so-called hidden curriculum ¹⁴ – a set of norms, values, and behaviors conveyed in implicit and explicit manners in the clinical learning environment – that stems from established senior residents and attending physicians who are tired and stressed themselves. In this way, the goal of coaching is to disrupt the cycle of burnout in medicine that feeds on itself.

Results

Given our program is in the descriptive pilot phase, the initial assessments are qualitative in nature, conducted via informal interviews with student participants. Members from our management team (the trainee authors of this manuscript) contacted participants for either in-person or email interviews. The conversations included general questions regarding the most valuable aspects of coaching, pertinent takeaways the students learned from their experience, and areas for improvement for the program. The informal nature of the interview allowed the students to speak freely and add any experience or thoughts on coaching they deemed relevant. Notes were transcribed during the in-person interviews and records were kept from the email interviews for a total survey of 25 fellows who underwent individualized coaching.

The responses from students are excerpted into a word cloud with the frequency of word choice represented by increasing weight in the cloud (Figure 1). The interviews were reviewed by the management team, and the themes below were those that were most often mentioned. Students’ words were kept in quotations whenever possible to preserve their intentions.

Figure 1.

Word Cloud Generated From Student Testimonials With Frequency of Word Choice Represented With Increasing Weight in the Cloud. Of note, words like “will,” “can,” “new,” and “goals” are heavily weighted, representing the forward-facing and proactive nature of coaching in shaping the student’s future.

Georgetown medical students, reflecting on their experience with coaching, acknowledged its importance in allowing them a space for self-care. One remarked that due to the busy schedule of medical school, students seldom had “the opportunity to stop and think about our medical decisions, the fates of our patients, or our fears about our future careers.” Coaching has given them the opportunity to step back and find meaning and value in the work. Others have noted that coaching has made them aware of their own critical self-dialogue. One student realized the expectations she put on herself through constant should statements, and how intentionally and mindfully changing her language would also change her thoughts. By incorporating different vocabulary about why and how students want to accomplish their goals, their mindset shifts from judgmental to proactive.

Compassionate Communication

On an interpersonal level, students have reported that the active listening and compassionate communication techniques coaches use model the ways good physicians communicate. The goals in both relationships are similar, as both coaches and physicians want their clients or patients to feel supported, heard, and cared for. One student noted that his coach “provided me with an insightful perspective on how to listen to others as well as ask key questions that allow others to open up.” As a result, many feel more comfortable engaging patients and families at the bedside after working with and learning from their coaches.

Finally, students have expressed that without coaching they noticed “the demands of training had already started to create counterproductive coping strategies” and how coaching allowed them to keep sight of the humanity that initially brought them to medicine. In this way, coaching has provided a valuable strategy to take care of medical students in their early phases of training, when they are forming their identities and reconciling their expectations of medicine with its reality. It provides a way to form coping strategies and process experiences at an early stage before maladaptive behaviors and thought patterns take form.

Students Drive Continuous Quality Improvement

Students have also identified critical feedback for the program. They expressed interest in more frequent group meetups, so that they may connect on shared experiences with one another. A theme in the post-coaching surveys was the loneliness in medical students, and students felt that while coaching was useful, group activities provided a greater sense of community. Further, in the initial cohort, all students who attended the workshop were obliged to participate in coaching. Feedback and experience over seven cohorts has shown us that assigning coaches to all participants generates a lower engagement rate as it frames coaching as something students have to do, rather than something they choose to do. Our coaches unanimously agree that a desire to change is a pre-requisite for a transformative coaching experience. Not all students are ready or interested in having a coach. We want to support those who are.

Discussion

A larger study evaluating and quantifying the impact of this program on current and future participants is underway. While verbal and written feedback of A Whole New Doctor has been overwhelmingly positive and transformational for students, we are beginning to quantify effects in this program with formal evaluation. Using the Kirkpatrick Evaluation Model, we have collected data on participant reaction, learning, and behavioral changes following coaching interventions in cohort seven. The Self-Awareness Outcomes Questionnaire (SAOQ) will be used as an objective measure to assess behavioral change.

We acknowledge that one weakness of our strategy to date has been the need for formal evaluations and quantitation of the positive changes students report. The positive feedback and continued student engagement during this pilot portion of our program has encouraged us to continue to the next phase of development including repeated measures testing with each participant serving as their own control pre- and post-engagement with our program. In levels one and two of the Kirkpatrick model, reaction and learning, respectively, we are collecting data on participants’ engagement and attitudes towards coaching and their understanding of polarities as taught during the workshop. In level three, behavioral change, the pre- and post-coaching intervention measurements will be taken using the SAOQ. These analyses will demonstrate the efficacy of our interventions and where we may still improve. We plan to publish the data in a future paper, pending IRB approval. Based on feedback, future iterations of the program will also focus on offering strengths and leadership skills assessments as well as a larger group component for reflection.

Conclusion

In summary, our pilot coaching program of A Whole New Doctor has received positive feedback from students early in their medical training. It will be important to further scale our program to reach an increasing number of students and evaluate participants for the long-term effects of our interventions.