By: Kathryn Ritter and Lalena M. Yarris
At the 2022 International Conference on Residency Education, a lively session debate explored whether coaches could also be assessors in graduate medical education (GME). For the purposes of debate, two speakers each argued opposing positions:
- Con: The role of the coach is to engage in a psychologically safe, longitudinal relationship with the learner in order to help them uncover learning gaps and solutions through thoughtful questioning and reflective listening.1 When coaches participate directly in learner assessment or promotion decisions, a conflict of interest occurs that threatens the effectiveness of the coach-learner relationship.
- Pro: Residents and fellows, like athletes, musicians, or chess players, can only achieve optimal growth and peak performance from deliberate practice.2 This requires direct observation and feedback from a coach (with expertise). With longitudinal relationships between the coach and trainee, safety can be achieved with coach involvement in assessment and summative competency decisions. In fact, the trainee wants the coach involved – because they know the trainee best.
The overwhelming vote of the audience in this session was for the “pro” argument – that in postgraduate medical education, it makes sense for coaches to be involved in assessment and summative competency decisions. However, these two scenarios describe fundamentally different types of coaches: the “con” example describes a leadership/growth coach whereas the “pro” example describes a feedback/skills coach. While this debate aimed to spark conversation rather than argue best practices, it did raise questions: How are definitions of advisor, mentor, and coach applied in residency and fellowship training programs, and which of these may serve as assessors? Which types of coaches are best suited to GME training? Further, how can small programs with few core faculty ensure all of these roles are filled in a way that protects learner psychological safety while also facilitating the acquisition of expertise? In order to explore these questions, it is helpful to first consider working definitions of assessor, advisor, coach, and mentor.
An assessor measures the learner’s performance and determines their progress toward specific learning outcomes. Examples of assessors in GME include:
- A clinical attending directly observes a resident leading the resuscitation of a critically ill patient, and they complete a workplace-based assessment form about the resident’s performance.
- An attending completes a standardized direct observation tool (SDOT) while observing a resident place a central line using a task trainer.
An advisor provides guidance about a specific event, educational problem, or situation, often based on the advisor’s own experience and expertise. GME learners may receive advice from a variety of formal and informal advisors. Learner acceptance and incorporation of advice may vary, based on their own needs and desires, their relationship with their advisor, and their perceptions regarding the quality of the advice. Some examples of advising in GME include:
- Residents are matched with a faculty advisor prior to orientation. They meet quarterly to check in about academic progress, clinical performance, and wellness. The advisor provides guidance based on their own experience, their knowledge of GME policies and procedures, and their areas of expertise.
- A trainee works with an attending in an episodic patient care environment. The attending offers specific strategies for improvement, based on their perception of the resident’s performance and areas for growth.
A coach helps a learner consistently strive toward their goals. Coaches ask learners open-ended questions that spark critical reflection. The coach can help the learner make connections or discover new insights, but the coach should not dominate the conversation in these meetings. In learner-driver discussions, coaches guide learners through self-assessment to discover performance gaps and form strategies to bridge them.1 While leadership/development coaches do not typically observe performance or have the “right” answers, skills or feedback coaching may include observation and providing guidance, or coaching with wisdom.3 Coaching occurs in many different settings in GME and may include:
- A senior resident is having difficulty deciding between two fellowships. Their coach asks them open-ended questions about what brings them fulfillment and what they value in their career. These questions help the senior resident critically reflect on their fellowship options and make a decision.
- A resident meets with a coach to discuss their performance on the standardized in-training exam. The coach asks them what made the exam challenging and what resources they used to study for the test. With the coach’s assistance, the resident writes a study plan with specific learning goals, and schedules regular coaching meetings to check-in about the resident’s progress.
A mentor relies on their understanding of the mentee and their own wisdom to guide and support the trainee longitudinally through residency or fellowship. Like advisors, mentors may be assigned, but trainees will often seek out their own formal or informal mentors, and they may approach different mentors for specific needs. The mentor often serves as a role model for the trainee. Examples of mentoring in GME include:
- A resident who is on a remediation plan is assigned a specific mentor to support them through the process of remediation.
- A fellow interested in academics seeks out the mentorship of a faculty who has a career path they admire and would like to pursue.
Educators in GME act as assessors, advisors, coaches, and mentors. These roles are inevitably intertwined. Since most GME faculty work clinically with and assess every learner in the program, it is not feasible to completely isolate assessment from coaching. Faculty members may play multiple roles for each trainee. For example, when a resident meets with their research mentor to discuss their scholarly project progress, the research mentor may integrate coaching with wisdom strategies in this meeting.
Within a GME program, faculty members contribute different strengths and areas of expertise as assessors, advisors, coaches, and mentors. Educational leaders should leverage these assets when identifying how faculty members may serve in these capacities. It is important to ensure that trainees have a diverse network of faculty members fulfilling these key roles. This facilitates a balance of assessment, advising, coaching, and mentoring to optimally promote the trainee’s development.
About the authors:
Kathryn Ritter MD, is an Instructor in Emergency Medicine at the Oregon Health & Science University in Portland Oregon
Lalena M Yarris MD MCR, is a Professor of Emergency Medicine at the Oregon Health & Science University in Portland Oregon
Acknowledgements: The authors thank Nicole M Deiorio, MD, for discussions related to this piece and for critical review.
1. Deiorio NM, E Skye, L Sheu. Introduction and definition of academic coaching. In: Deiorio NM, M Hammoud, eds. American Medical Association Accelerating Change in Medical Education Coaching Handbook. 2017:1-5.
2. Ericsson, KA. Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine. 2004;79(10):S70-81.
3. Marcdante K, D Simpson. Choosing when to advise, coach, or mentor. Journal of Graduate Medical Education. 2018;10(2):227-8.
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