How do we improve in the face of complexity? Atul Gawande has studied this question with a surgeon's precision. He shares what he's found to be the key: having a good coach to provide a more accurate picture of our reality, to instil positive habits of thinking, and to break our actions down and then help us build them back up again. "It's not how good you are now; it's how good you're going to be that really matters," Gawande says.
By Atul Gawande
How do professionals get better at what they do? How do they get great? I think it's not just how good you are now, I think it's how good you're going to be that really matters. As a surgeon getting better means I save more lives. And I have also seen the consequences of different philosophies of betterment around the world. I'd like to share what I have observed.
The Two Views of Professional Improvement
There are two views about this. One is the traditional pedagogical view. That is that you go to school, you study, you practice, you learn, you graduate, and then you go out into the world and you make your way on your own. A professional is someone who is capable of managing their own improvement. That is the approach that virtually all professionals have learned by. That's how doctors learn, that's how lawyers do, scientist, and musicians. And the thing is, it works. Consider for example legendary Juilliard violin instructor Dorothy DeLay. She trained an amazing roster of violin virtuosos: Midori, Sarah Chang, Itzhak Perlman. Each of them came to her as young talents, and they worked with her over years. What she worked on most, she said, was inculcating in them habits of thinking and of learning so that they could make their way in the world without her when they were done.
Now, the contrasting view comes out of sports. And they say "You are never done, everybody needs a coach." Everyone. The greatest in the world needs a coach.
So I tried to think about this as a surgeon. Pay someone to come into my operating room, observe me and critique me. That seems absurd. Expertise means not needing to be coached
So then which view is right?
I learned that coaching came into sports as a very American idea. In 1875, Harvard and Yale played one of the very first American-rules football games. Yale hired a head coach; Harvard did not. The results? Over the next three decades, Harvard won just four times. Harvard hired a coach.
And it became the way that sports works. But is it necessary then? Does it transfer into other fields?
I decided to ask, of all people, Itzhak Perlman. He had trained the Dorothy DeLay way and became arguably the greatest violinist of his generation. One of the beautiful things about getting to write for "The New Yorker" is I call people up, and they return my phone calls.
And Perlman returned my phone call. So we ended up having an almost two-hour conversation about how he got to where he got in his career.
And I asked him, I said, "Why don't violinists have coaches?"
And he said, "I don't know, but I always had a coach."
"You always had a coach?"
"Oh yeah, my wife, Toby."
They had graduated together from Juilliard, and she had given up her job as a concert violinistto be his coach, sitting in the audience, observing him and giving him feedback.
"Itzhak, in that middle section, you know you sounded a little bit mechanical. What can you differently next time?" It was crucial to everything he became, he said.
My Own Coaching Experience
Turns out there are numerous problems in making it on your own. You don't recognize the issues that are standing in your way or if you do, you don't necessarily know how to fix them.And the result is that somewhere along the way, you stop improving. And I thought about that, and I realised that was exactly what had happened to me as a surgeon.
I'd entered practice in 2003, and for the first several years, it was just this steady, upward improvement in my learning curve. I watched my complication rates drop from one year to the next. And after about five years, they levelled out. And a few more years after that, I realised I wasn't getting any better anymore. And I thought: "Is this as good as I'm going to get?"
So I thought a little more and I said ... "OK, I'll try a coach." So I asked a former professor of mine who had retired, his name is Bob Osteen, and he agreed to come to my operating room and observe me. The case -- I remember that first case. It went beautifully. I didn't think there would be anything much he'd have to say when we were done. Instead, he had a whole page dense with notes.
"Just small things," he said.
But it's the small things that matter. "Did you notice that the light had swung out of the wound during the case?", he asked "You spent about half an hour just operating off the light from reflected surfaces". I hadn't noticed. "Another thing," he said, "Your elbow goes up in the air every once in a while. That means you're not in full control. A surgeon's elbows should be down at their sides resting comfortably. So that means if you feel your elbow going in the air, you should get a different instrument, or just move your feet." It was a whole other level of awareness. And I had to think, there was something fundamentally profound about this.
Osteen was doing what great coaches do: they are your external eyes and ears, providing a more accurate picture of your reality. They're recognising the fundamentals. They're breaking your actions down and then helping you build them back up again.
After two months of coaching, I felt myself getting better again. And after a year, I saw my complications drop down even further. It was painful. I didn't like being observed, and at times I didn't want to have to work on things. I also felt there were periods where I would get worse before I got better. But it made me realize that the coaches were onto something profoundly important.
Systems Scale Coaching
In my other work, I lead a health systems innovation centre called Ariadne Labs, where we work on problems in the delivery of health care, including global childbirth. As part of it, we had worked with the World Health Organization to devise a safe childbirth checklist. It lays out the fundamentals -- the critical actions a team needs to go through when a woman comes in in labor; when she's ready to push; when the baby is out; and then when the mom and baby are ready to go home. And we knew that just handing out a checklist wasn't going to change very much, and even just teaching it in the classroom wasn't necessarily going to be enough to get people to make the changes that you needed to bring it alive. And I thought on my experience and said:
We found some incredible partners, including the government of India, and we ran a trial in 120 birth centres. In Uttar Pradesh, in India's largest state. Half of the centres we just observed, but the other half got visits from coaches. We trained an army of doctors and nurses in basic coaching practices - observation for a start.
One of the skills, they had to work on - that turned out to be fundamentally important - was communication. Getting the nurses to practice speaking up when the baby mask is broken, or the gloves are not in stock, or someone's not washing their hands. And then getting others, including the managers, to practice listening. This small army of coaches ended up coaching 400 nurses and other birth attendants, and 100 physicians and managers. We tracked the results across 160,000 births.
- In the control group who didn't have coaching they delivered on only one-third of 18 basic practices that we were measuring. And most important was that over the course of the years of study, we saw no improvement over time.
- In the other group, who got four months of coaching, we saw them increase to greater than two-thirds of the practices being delivered. It works. We could see the improvement in quality, and you could see it happen across a whole range of centres that suggested that coaching could be a whole line of way that we bring value to what we do.
With coaching at this scale, you can imagine the whole job category that could reach out in the world and that millions of people could fulfil.
Surgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching. Atul Gawande is author of several best-selling books, including Complications: A Surgeon's Notes on an Imperfect Science, Better: A Surgeon's Notes on Performance, Being Mortal: Medicine and What Matters in the End and The Checklist Manifesto.