Building the Team: Residents as Clinical Coaches

Introduction

Individualized coaching that utilizes direct observation is an effective strategy to remediate struggling learners and facilitate growth of all learners.¹ Coaching utilizes formative assessment and iterative feedback centered around individualized learner goals in order to promote ongoing growth of the trainee. While coaching is gaining interest and attention within the realm of medical education, training in coaching theory and techniques is often limited and focused primarily on faculty educators and remediation of trainees rather than being approached as a universal strategy.² Moreover, while best practice dictates separation of evaluator and coach roles, this distinction is difficult in practice. Given the growing role of coaching as a key facet of medical education, it is important that residents, particularly those pursuing medical education careers, have improved knowledge of and comfort with effective coaching techniques.

In internal medicine, dedicated resident teaching rotations provide exposure to medical education theory and opportunities to develop teaching skills. Few curricula have addressed dedicated clinical coaching training for residents and, to the authors’ knowledge, none describe dedicated experiential coaching and direct observation training for internal medicine residents to prepare them for careers in medical education.³ With this in mind, we redesigned an existing internal medicine senior resident teaching rotation to achieve three parallel aims:

1. improve senior resident familiarity and comfort with core principles of coaching in medical education;
2. provide opportunities for resident development of skills in coaching through direct observation;
3. increase non-evaluative feedback opportunities for internal medicine clerkship students.

Intervention

In July 2020, the authors redesigned a two-week internal medicine resident teaching elective at a single large, urban academic institution. Senior internal medicine and medicine-pediatrics residents are invited to participate in the teaching rotation. One resident enrolls in the rotation each two-week block. All residents in the internal medicine residency medical education leadership track are required to participate in this rotation during their senior year—it is an optional elective for other senior medical residents. Resident participants are responsible for teaching medical students on their six-week inpatient internal medicine core clerkship. Notably, residents on the teaching rotation do not have a role in evaluation of these students.

At the start of the teaching rotation, residents watch a one-hour didactic video covering core principles of coaching including guidance on effective direct observation, student-driven goal setting, collaborative action plan development, and types of learner deficits. Didactic material was developed by our institution’s core undergraduate medical education coaching faculty and was specifically adapted for resident coaches. Residents also receive training on use of an electronic QR-based feedback tool to facilitate coaching best practices including SMART (Specific, Measurable, Achievable, Realistic, Timely) goal-setting, targeted feedback, and concrete action plan development. The tool serves as a framework for synchronous verbal feedback or asynchronous written feedback. Observations and feedback can be tracked electronically by students and clerkship administrators through the tool but are not used for evaluative purposes.

During the rotation, residents coach three clerkship students daily during scheduled direct observations of pre-rounding patient encounters and subsequent patient presentations. Oral presentation observations occur in two formats: either one-on-one, real-time observation of student presentations on rounds or observation of student presentations in one-hour long, virtual small-group meetings. With the aid of the relevant QR-based feedback tool, the student-coach pair develop an individualized goal prior to each session and a concrete action plan at the conclusion of each session, along with specific actionable feedback provided by the resident coach. Residents have virtual bi-weekly office hours to discuss relevant student cases and coaching strategies with coaching faculty. Finally, residents lead case-based didactic sessions and small group chalk talk sessions to support a diverse portfolio of teaching skills.

Results

From July 2020-March 2021, 16 residents completed the teaching rotation, coaching 139 internal medicine clerkship students. Sixty-nine percent (11/16) of residents completed the post-course evaluation (see Table). Residents felt that completing the pre-rotation training led to a better understanding of coaching and direct observation fundamentals. Most residents strongly agreed that the workload was appropriate for a teaching rotation. All residents agreed or strongly agreed that after completing this rotation, their skills as a medical educator improved.

The clerkship post-course evaluation response rate was 88% (123/139), although not all students completed all items. Seventy-nine percent (93/118) of students reported that explicitly setting goals for direct observation improved the feedback they received and 79% (90/114) felt setting a specific action plan for improvement was helpful.

Discussion

We adapted a pre-existing two-week senior resident teaching rotation to successfully prepare resident educators to become coaches by providing in-person, non-evaluative coaching for student learners. Importantly, this rotation provides built-in direct clinical observation to enhance coaching efficacy, which is uncommon in existing academic coaching programs where the majority of coaches do not directly observe their trainees.² The rotation was perceived to be an appropriate workload for resident trainees, while improving resident understanding and comfort with core coaching principles through didactic and direct experiential training.

Our model utilizes coaching principles yet did lack continuity between the learners and coach. Coaching theory suggests that the coach-learner dyad be structured based upon the particular goals of the program. From our experience, short-term coaching relationships may be adequate for standard learners, as opposed to the long-term coaching employed for struggling trainees. This rotation’s development was aided by the involvement of dedicated coaching faculty. However, with the exception of bi-weekly office hours, a preexisting coaching practice is not a prerequisite. In fact, this rotation offers a template and transportable content to implement resident-driven coaching at institutions that otherwise cannot support dedicated coaching faculty.

Our curricular adaptations demonstrate a feasible and reproducible framework that not only incorporates coaching education and experience for residents but also expands capacity to provide formative feedback and coaching for clerkship learners. If coaching theory and techniques become more integrated into daily practice, it may shift the culture of learners towards a more consistent growth mindset. Moving forward, we hope to continue to grow this program with consideration of scaling this approach to non-clerkship learners, customizing observation and feedback to specific learner needs, and developing longitudinal approaches that may help learners in need of additional focused coaching.