Doctor Coach

Don't teach more, coach better!

Establish Practice Objectives

Deliberate practice relies on clear objectives about the specific component skills to be practiced, and establishes how the practice sessions will be constructed with available opportunities.

Effective practice is intentionally designed. Informed by your observations, assessment and feedback dialogue, the SPOTS approach ensure that you and your learner collaboratively design an effective practice plan to intentionally capitalize on the opportunities afforded by your practice environment to meet your learner’s unique needs.

Define the SPECIFIC skills and the intended outcomes

Based on your coach’s assessment and the results of your feedback conversation, determine the specific skill or set of skills that your learner will practice, as well as the intended outcome of their practice. Setting practice objectives is often a good time to revisit your SMART goal setting conversation. This ensures that you and your learner continue to share a common vision of the skill(s) to be practiced, and mutually agree upon how the learner’s progress and achievement will be defined. Ask your learner to describe to you, in as much detail as possible, the skill(s) they intend to practice, followed by “What will it look or feel like to have achieved sufficient practice?” and “How would someone other than you know that you had practiced sufficiently?” Collaborating with your learner to answers these questions serves as the foundation of your practice plan.

Be clear on the PURPOSE for working on this skill now

Practice should be designed to achieve your mutually agreed upon SMART goals, and to advance your learner’s achievement of developmental milestones for a given skill. The purpose of your practice plan should thus focus on:

  • Strengthening component skills that are holding the learner back from achieving the next milestone in their overall skills mastery.
  • Reinforcing a newly achieved skill that, when sufficiently practiced, will solidify the foundation of their overall performance.
  • Correcting improper technique that will lead to poor performance or clinical errors.
  • Advancing an area of relative strength.
  • Improving self-assessment in an area of relative learner under-confidence.

Importantly, by clearly identifying the purpose of practice you will also facilitate learner self-reflection. Merely performing a skill, even repetitively and with feedback, is not truly practice and does not by itself confer learning. By encouraging deliberate self-reflection you will help your learner transform their performance and your coaching into effective practice, and advance their development of insight.

Identify OPPORTUNITIES for practice

Designing and capitalizing on the opportunities available for you to coach your learner in practice is critical to an effective practice plan. Begin by discussing with your learner the specific types of patients and experiences that will target their practice and performance goals, and suggest ways to integrate their practice and goals into their daily clinical experiences. Consider opportunities for organic practice in the clinical environment as well as simulated experiences that can range from hypothetical clinical scenarios to high fidelity simulation. These types of opportunities represent different ways to tailor the learning environment.

Is your learner practicing an individual or straightforward skill? If so, consider temporarily constraining the scope of their patient assignment in order to isolate their practice and ensure frequent and sufficient repetition. For example, you might assign a medical student to spend the morning rooming patients together with a patient care assistant in order to practice taking blood pressures. Alternatively (depending on the skill and the patient population), you might agree to intentionally add practice to routine care. For example, agree with the intern that she will perform and describe an ophthalmologic exam on all teenage patients seen in a given week. Simulated skills trainers are also perfect for focused practice of a single skill.

Is your learner practicing components of a complex skill or set of integrated skills? If so, design practice to increase fluency and integration of the individual skills. Again, consider temporarily constraining the scope of practice to isolate the desired skill, such as observing the medical student perform and report a full physical exam on all newborns admitted to the service for a week, or assigning and supervising the junior resident to take all admission calls from outside providers for a day. Simulation is a safe way to allow early learners to safely practice integrating a set of related skills that they have not yet mastered individually.

Is your learner practicing the transfer of an acquired skill to new settings? If so, expand the scope of their care (or practice) to as many new patient contexts as possible. For example, agreeing with the intern that she will perform and describe an ophthalmologic exam on all of her patients (of any age) for a week, or supervising the medical student to interpret ECGs on all patients admitted in the next two weeks.

Is your learner a novice or advanced beginner? If so, it is especially important to constrain the scope of clinical practice to isolate individual skills.  You may also want to use high or low fidelity simulation for practice in situations that require significant learner training and entrustability prior to independent practice and to help learners to begin to integrate skills that they are still developing.

Is your learner more advanced or competent?  If so, it is even more important to determine which aspects of his/her performance to practice.  Using “what if” questions can help to ensure that you continue to push your competent learner toward becoming more proficient. Your learner may be ready to work on transfer of skills to a new or more complex setting. Teaching experiences can also help competent learners to explore more deeply a skill or topic with which they are comfortable.

Tailor practice TACTICS and coaching to meet the objectives

Given the specific practice objective and opportunities available for practice, determine how your learner should begin practicing (see Engaging in Apprenticeship section for more information on types of practice). Does the environment dictate that your learner begins with heavily supervised or simulated practice (see below)? Should you model the skill so that your learner begins by mentally practicing, or can you begin by supervising the learner in real time caring for a patient?

Adjust and advance your practice plan continuously. Guided and supervised practice should lead to independent practice – and then make a plan with your learner for re-observation and feedback, with further adjustments to technique or levels of autonomy as appropriate. On occasion, your learner may benefit from a return to modeling or guided practice to hone technique, but be sure to step back again when appropriate. Remember, the availability of immediate and continuous feedback is the key to successful skills practice. Provide feedback in the form of short, frequent “bites” that are prioritized to the specific practice objectives and based on your observations. Deliberate attention to making these adjustments and being flexible during practice is the key to making you a great coach!

Be sure to allow time for quick coaching check-ins – often at the end of a day or session. Check-in’s are essentially mini feedback conversations that will:

  • Give your learners time to reflect on their performance (reflection ON action), allowing them to mentally deconstruct their own performance, compare their self-assessment to your coach’s assessment, and therefore practice coaching themselves.
  • Track your learner’s progress and identify intermediate progress.
  • Help you determine your learner’s readiness for more autonomy and independent practice, as well as readiness to tackle new skill components, more fully integrate skill, or practice their skills in a new context or environment.
  • Promote learner motivation to sustain practice and work toward their goal, and help you manage and problem-solve around frustration when needed.

Be flexible - tailoring is achieved through mini-cycles of iterative practice, reflection and frequent adjustments. Ongoing direct observation is your responsibility as coach, but over time your learner should become increasingly responsible for self-observation (or reflection IN action). Make a habit of routinely discussing each of your assessments (or reflection ON action), and adjusting the practice plan (or reflection FOR action) as needed, until the specified practice objectives are met.

Consider patient and learner SAFETY and supervision needs

By definition, effective practice is designed to create an environment in which errors and mistakes are tolerated (or even invited), and serve as a building block for learning. Learning through practice in patient care creates a crucially important and unique challenge to the clinical coach: balancing the learner’s need for effective practice with patient safety and satisfaction.

As you begin to design a practice plan with your learner, begin by asking yourself:

  • What is the learner’s current skill level, and what are the types of errors that the learner is likely to make? Should practice begin in a simulated environment?
  • How comfortable are you with the learner’s ability to accurately self-assess when they are working above their current level of competence?
  • Given the nature of the skill and practice objectives, what are the relative risks of an error, a delay in care or a duplication or prolongation of services to the patient?
  • How can mental practice (e.g. “what if” or “how would you” scenarios) be blended effectively with real-time practice?
  • How will you balance supervision (modeling, guided and supervised practice) with autonomy (independent practice)?
  • How will the learner alert you to practice situations in which s/he feels uncomfortable, and how will you ensure that the learner feels comfortable speaking up?
  • What are your expectations about how (and when) a clinical error by the learner will be addressed?

The need for an intentional discussion with your learner about these questions, prior to beginning practice, cannot be overemphasized.