Time and again, psychological studies show that one of the main differences between weak and strong students is metacognition (a student’s awareness of his or her level of understanding). Good students know when they have mastered material, but weaker students tend to be grossly overconfident.

Among medical residents, this can certainly be a problem for those struggling to keep up with the pace of clinical duties, daily learning of knowledge and skills, and a myriad of other responsibilities. A new resident coaching model is emerging in residency programs to help these aspiring doctors improve quickly in their training. In the following Q&A with Roy Phitayakorn, MD, I explore the reasons why residents might be having problems and what the mentoring model can do to help.

Dr. Roy Phitayakorn is a general and endocrine surgeon and the Director of Surgical Education Research at Massachusetts General Hospital and an Assistant Professor of Surgery at Harvard Medical School. He is also the Education R&D consultant to NEJM Group.

Josette Akresh-Gonzales: In an article called “Why we overestimate our competence” on the American Psychological Association blog, Cornell University social psychologist David Dunning, PhD, reports that “the least competent performers inflate their abilities the most…[and] the reason for the overinflation seems to be ignorance, not arrogance.” Does this finding apply to resident physicians? If so, what are some ways that residents can become more aware of their need to improve?

Roy Phitayakorn, MD: Resident physicians are under enormous competing pressures with little or no feedback on their actual performance. Sometimes the feedback they do receive is contradictory, so they are uncertain if they really need to improve in a certain cognitive/behavioral domain or not. Therefore, I think the best way for residents to improve is to look at their data as a whole and spend some time doing guided reflection with a coach or mentor on what the data show exactly and how or what they want to improve.

JAG: What are some of the other factors that contribute to a resident failing an in-training or board certification exam, say, or not meeting expectations in clinical tasks?

RP: One approach to classifying resident deficiencies is the KSA approach — Knowledge, Skills, and Attitude. Let’s take them one at a time: Residents’ performance deficits on knowledge-based assessments may be a result of their not prioritizing time to study, studying incorrect materials, or poor test-taking skills.

Skill deficits, such as problems with doing certain clinical procedures, may require more effective practice time as well as expert feedback to accelerate learning of new skills.

Attitude issues may stem from psychological well-being challenges such as burnout. In my opinion, attitude issues are the most difficult ones to address — and are so often the most ignored within a residency program until a critical issue gains the attention of the patient safety group or the hospital’s medicolegal team. Of course, medical problems such as hypothyroidism or attention-deficit disorder may also cause issues in any of these domains and should be ruled out early.

JAG: Can you discuss the recent trend to assign mentors or coaches to struggling residents?

RP: We recognize that all physicians, residents and attendings, benefit from mentorship and coaching. Unfortunately, the ones who need it most are often unsure about how to find a mentor or coach to help them. Therefore, many residency programs have started assigning all resident physicians a mentor and/or coach to help them navigate their development into caring, highly-skilled physicians.

These programs often consist of regular meetings where the residents will review their evaluation data with their mentor/coach and create an action plan about what they would like to improve before their next meeting. NEJM Knowledge+ is a great way to receive objective data about how a resident’s cognitive knowledge is developing and could be used for remediation as well.

JAG: Yes, in fact, program directors have access to numerous reports in NEJM Knowledge+ showing residents’ progress through the learning material and their performance in specific topic areas. Do you think a resident coach can also help to improve a learner’s self-awareness over time?

RP: Metacognition is difficult to develop without both objective data, feedback, and a willingness on the resident’s part to change. I think emotional intelligence is a hidden piece to some of that willingness to accept feedback and change behaviors that do not reconcile with objective data. Regular assessment and development of emotional intelligence is standard practice in many industries except medicine. Hopefully we will catch up someday as more research is published in this area.

JAG: Can you recommend good resources for coaching residents in general and coaching them on self-awareness in particular?

RP: The first thing I’d suggest is to look to working resident coaching and mentoring programs as a model, such as the one at Massachusetts General Hospital (MGH): MGH Internal Medicine Professional Development Coaching Program. There, “Each trained volunteer faculty member coaches two to three residents and remains their coach for their entire residency. All residents are included in the coaching program. Interns and faculty meet quarterly, usually for an hour each quarter.”

And at Stanford School of Medicine, the Stanford Pediatric Residency’s Coaching Initiative provides “longitudinal assessment and feedback to residents throughout their training, and to help residents develop skills of lifelong learning and self-reflection. Each resident is assigned a specific Faculty Coach who observes and guides that resident across multiple rotations, inpatient and outpatient settings, and training years. The Coach observes the resident in multiple clinical situations (rounds, clinic, initial H&P, handoffs, supervisory encounters, care conferences, and others) and provides specific and directed feedback aimed at strengthening clinical skills.”

Another resource is this slide set provided by the Massachusetts Medical Society, entitled “Physician Coaching and Mentoring Programs: Surviving the Tsunami of Change,” Presented by Susan F. Reynolds, MD, PhD., President and CEO of The Institute for Medical Leadership, to the Massachusetts Medical Society’s Physician Leadership Institute, on February 1, 2012. It includes information on setting up a trusting relationship between coach and resident, and using goal setting and accurate data to drive ongoing conversations. Here’s a sample piece of advice from that presentation:

Best Physician Coaching Strategies

  • Listen/Build Rapport/Trust – in person meetings
  • Identify resistance issues (e.g. past training, law suits)
  • Define clear coaching goals and timeline
  • Emphasize patient safety and quality of care (motivators)
  • Accept that cost savings may not be a motivator
  • Give timely feedback
  • Avoid email except for scheduling meetings
  • Give Rewards!

Have you participated in a mentorship or resident coaching program at your residency? If so, how did it work and did you find it helpful?