Introduction

With the push for competency-based medical education (CBME), an increasing emphasis has been placed on individualized trainee development. Near-peer coaching has emerged as a valuable tool for enhancement at multiple levels within academic medical systems [1, 2]. It has also been shown to enhance self-directed learning through focus on deliberate practice and reflection on performance [3].

Peer and near-peer coaching in medical education has shown benefit in improving trainees’ academic learning as well as peer coaches’ teaching skills [4, 5]. In surgical education, peer/near-peer coaching has primarily been described in the context of resident trainees coaching other residents in both operative and non-operative skills [6, 7]. However, most reported coaching initiatives have concentrated solely on enhancing trainees’ operative and technical skills during residency training with limited focus on clerkship students (i.e., third-year medical students rotating in surgery).

Surgical clerkship is an important core rotation and the clerkship experience has been shown to directly influence medical students’ career interest in surgery [8, 9]. To our knowledge, no previous papers have reported the used of peer or near-peer coaching as a method used for health systems science (HSS) curricula implementation during surgical clerkship, a science which refers to the critical competencies necessary for high-quality healthcare delivery. Real-time implementation of an effective HSS curriculum during clerkship rotations remains a challenge and many undergraduate medical education (UME) programs have struggled to identify ways to incorporate HSS in a way that resonates with students [10,11,12]. This is in part, due to the natural preference of students to place higher prioritization on licensing examination preparation topics/content and faculty’s limited time allocation to mentoring students in these topics [11]. Some programs have established preclinical HSS courses and HSS content assessments are formally available as a National Board of Medical Examiners (NBME) assessment. However, given the lack of universal adoption in post-clinical UME curricula, and the generic nature of the NBME assessment, clinical-setting specific content mastery is often not prioritized [13].

To optimize students’ surgical clerkship learning and encourage interest in the surgical pipeline, we developed a resident-student near-peer coaching program at our institution in 2020–2021 and pilot-implemented the program in 2021–2022. All general surgery residents in postgraduate training years PGY2–PGY5 (including research residents) were eligible to participate in the near-peer coaching program on a volunteer basis without receiving protected time to meet with student coachees. Interns (PGY1) was excluded from participation as coaches due to potentially lacking familiarity with our local health system. Residents served as coaches for surgical clerkship students with a goal to improve students’ practice of health systems science (HSS) [14] without compromising their clinical learning or efficiency of patient care delivery.

Enlisted coaches were provided with a coaching manual regarding HSS introduction as well as common challenges and scenarios that medical students face on the surgical clerkship, and then attended one in-person coach training session. Students participated in the coaching program via an opt-in approach. Student–coach pairings were restricted to residents who were not on the same rotation as the student in order to reduce potential conflicts that might influence student rotation performance evaluations (graded by residents). Coaching assignments were made at random by the resident lead of this program, though students had the option for a re-assignment if requested. Resident coaches were assigned 1–3 students and recommended to meet with their students at least three times (i.e., rotation beginning, mid-point, and endpoint) to provide HSS coaching support using a mutually agreed upon communication method (e.g., in-person, phone call, and virtual).

To continuously improve this near-peer coaching program, this study sought to identify, from resident coaches’ perspective, the implementation barriers and potential facilitators of effective HSS coaching provided by residents for surgery clerkship students at a single large, urban tertiary-care academic institution.

Methods

Study design and participants

The study used an explanatory sequential mixed method design. We conducted a survey with general surgery residents who once served as HSS coaches for surgical clerkship students. We then interviewed resident coaches to elicit their feedback and/or explanations of their survey answers (e.g., Did you feel effective as a coach? Why or why not?) This study was approved by the institutional review board (IRB).

Data collection and analysis

In part one of this study, all general surgery residents recruited to serve as coaches were sent a survey questionnaire at the end of the academic year to gain a baseline assessment of their experience serving as an HSS coach for surgery clerkship students. The survey consisted of 22 questions probing content such as demographics, overall experience coaching, perceived effectiveness as a coach, perceived benefit through engagement in coaching, an assessment of topics covered during coaching sessions, frequency/length of coaching encounters, and an initial probe of perceived challenges in the coaching experience. Overall experience coaching and perceived effectiveness as a coach were assessed via a 5-point Likert-scale. Surveys were initially pilot tested on 2 surgical residents not involved in the study and feedback used to refine questionnaire items to improve overall clarity prior to distribution. Residents participated on a volunteer basis. Descriptive statistical analysis was performed on survey data.

In part two, a subset of resident coaches were recruited to complete 1-h long semi-structured interviews, using a purposeful sampling approach. We intentionally recruited resident coaches to represent different PGY levels, genders, and patterns of survey responses. Interviews were designed focusing on four major areas: 1) resident background and experience with mentorship and coaching, 2) resident opinions on the perceived gap in learning for students on clerkships, 3) coach’s preparedness and views on their performance and effectiveness as a coach over the year, and 4) assessment of perceived barrier and facilitators of effective coaching. All interviews were conducted with Zoom (Zoom Video Communications, Inc, San Jose, CA), transcribed, and de-identified. Three trained surgical research fellows and two medical students independently coded each transcript line-by-line to identify emerging themes using Dedoose: Qualitative Data Analysis Software [15]. Discrepancies were resolved via consensus discussion until reaching consensus. Framework Methods [16] was used to analyze the data, including: familiarization and review of the data, identification of the thematic framework, coding and mapping the data, and interpretation. Thematic saturation was achieved at the end.

Results

Resident coach survey

A total of 20/30 (67%) active coaches completed the end-of-year coaching exit survey. Figure 1 shows the distribution of coaches by clinical training level. Of the residents included in the study, 13% (n = 4/30) were residents in research years. Survey results (Fig. 2) showed that more than 60% of coaches from PGY2 and research residents groups met with their assigned students 3–4 times on average throughout the clerkship rotation with each meeting lasting approximately 30–60 min. During the introductory meeting, 80% of coaches reported prioritizing setting and reviewing individualized clerkship goals with their students. By the end of the rotation, 70% of coaches (Fig. 3) reported feeling that their students had achieved the individualized learning goals set at the beginning of the rotation. Per coaches’ report, topics that were most commonly reviewed with students during coaching meetings (Fig. 4), included: 1) identifying study techniques specific to different clinical settings, 2) clinical skills practice, 3) health system navigation, and 4) time management. The most challenging part(s) of the coaching experience as reported by the majority of coaches included difficulties with assessing students’ needs and expectations.

Fig. 1
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PGY level of residents serving as surgical clearkship coaches

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Fig. 2
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Frequency and duration of meetings held with students during the coaching period

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Fig. 3
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Goal settings behaviors

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Fig. 4
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Common topics addressed during coaching sessions

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Resident coach semi-structured interviews

A total of 10 of the 20 previously surveyed resident coaches participated in interviews. Results assessed from the end-of-year coaching exit survey were used to elicit further explanation during the 1-h long semi-structured interviews. Primary themes emerging from these interviews spanned four major categories (Table 1 and 2): internal facilitators, external facilitators, internal barriers, and external barriers to effective coaching. The most common barriers and facilitators identified under each theme are described below.

Table 1 Barriers to effective coaching for surgical clearkships
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Table 2 Facilitators of effective coaching for surgical clerkships
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Internal barriers to effective coaching

Three internal barriers relating to resident coaches’ individualized attributes and skill sets were identified (Table 1). The two most frequently addressed by coaches included: 1) difficulties in building rapport and solidifying a collaborative relationship or 2) a lack of experience/confidence in executing common coaching strategies and techniques.

Coach demonstrated difficulties in building rapport with students

Half of interviewed residents reported experiencing some degree of difficulty in building rapport with students. Among interviewed coaches who expressed difficulties with rapport building, three sub-themes emerged. The first theme was a perception by coaches that it was difficult to get clerkship students to share shortcomings and rotation struggles due to the belief that most students show an aversion to vulnerability. One coach stated, “People aren’t going to tell you they are struggling just because you ask them. I just don't think that it's safe…[students] are afraid of being perceived as dumb or lazy.” A second subgroup reported struggling to build rapport and illicit student vulnerabilities and areas for improvement due to a perception that learners lacked insight regarding their strengths and weaknesses as evidenced by the following quote, “…Many students simply lack insight…I never had anybody come up to me and say I feel like I'm not good at X,Y, & Z things. Can you help me? Can you advise me?” The final subgroup of coaches who reported struggles with rapport building indicated that the perception that the coaching relationship was not organic, but rather operational and forced, served as a major barrier to establishing an authentic relationship with their students and eliciting actionable information.

Coach lacked experience or lacked confidence in coaching abilities

Some interviewed coaches indicated a lack of previous experience serving in a formal coaching or mentoring role which, in part, they felt attributed to some degree of their difficulties in coaching. This lack of experience manifested across a range of coaching task-related areas, including: 1) challenges with delivering valuable feedback or facilitating difficult conversations, 2) lack of preparedness in navigating individualized sessions, and 3) failure to emphasize student-driven goal setting during meetings. In addition, the perception of diminished value of the coach’s input with clerkship students in coaching pairings where the coach lacked clinical seniority (i.e., PGY level) emerged as a unique sub-theme expressed among junior residents serving as coaches. One coach commented,

“I think different levels of advice from different people carry different weight…. I think there was obviously a certain degree of ‘this is a second year resident who's telling me X, Y, & Z things versus this is a chief resident or an attending telling me certain things… medical students are pretty savvy in terms of what/who they [accept information] from and how they interact with it.”

External barriers to effective coaching

Five external barriers were identified to influence coaching efficacy from resident coaches’ perspective (Table 1). The two most commonly cited by interviewed coaches are herein further described.

Coach lacked data to facilitate valuable feedback exploration

Eight of 10 coaches (80%) acknowledged an increased challenge in delivering timely and valuable feedback due to not being assigned clerkship students rotating on the same clinical service. Coaches reported that although, dissociating the coaching assignment from the students’ assigned clinical rotation may have supported rapport building by mitigating any potentially negative impact on clinical evaluations, it created limitations in their ability to deliver timely or actionable feedback and/or gather feedback from other stakeholders that could be explored during coaching sessions. These challenges were especially magnified in scenarios where coaches perceived a disconnect in rapport and cases where the student did not actively seek out the coach’s input. In addition, some coaches indicated that poor communication by students due to fear of being reprimanded also created a unique barrier that limited their ability to adjust their coaching practices due to the lack of feedback on their role. One coach described,

“I [have to] gather the information I need in order to give appropriate feedback without being there. I gather that information, either by talking to the residents on the rotation or by eliciting it via the trust relationship I have with the student.”

Logistical challenges

Nine of 10 coaches (90%) reported logistical challenges in coordinating meetings with their assigned students. Given the student-driven approach to the coaching model, high variability in consistency of students taking the initiative to set up meetings also added to coaching challenges. Competing interests, such as juggling demanding clinical responsibilities, time constraints and managing availability, as well as finding new modalities such as video-calling platforms for meetings also added to these challenges. Lack of external incentives for some also contributed to feelings of demotivation. One coach highlighted the special challenge of scheduling meetings with students not on the same clinical service, “To get into contact at the beginning, the middle, and at the end [of the rotation], sometimes [is] really difficult because you are trying to coordinate respective service availabilities.”

Internal facilitators of effective coaching

Seven sub-themes emerged highlighting facilitators of effective near-peer coaching (Table 2). Likewise, the majority of interviewed coaches (80%, N = 8/10) reported some level of prior experience mentoring or coaching students from other previous roles (ex. sports, volunteer/extracurricular activities, etc.) which they perceived benefited them moving into the current role. These coaches reported emphasis on setting clear, student-driven, tangible goals early during their student interactions, and prioritized trying to deliver empathetic yet actionable feedback. All coaches indicated the importance of rapport building in establishing a solid platform for feedback delivery with students. Several coaches noted that consistency, accessible leadership, expressing vulnerability, and showing approachability and relatability also served to enhance the initial rapport building process. Providing students with empathetic yet actionable feedback and an accessible, judgement free safe space was pivotal in enhancing student learning and performance. One coach stated,

“I stress on the empathy or the tone of feedback, because you can have every other aspect of [good feedback]… but if it's not delivered in a way that's receivable, it's useless, right…? It can be goal-oriented, user-friendly, timely, and consistent. It can be all of the things … a solid gold bar on a silver platter; but if that gold bar is thrown at you, it’s not [going to] be received well regardless of the value.”

External facilitators of effective coaching

Five external facilitators were identified (Table 2). During the interviews, all coaches indicated appreciation of the supports from clerkship and residency program administrative staff, such as assisting with regular email reminders to student–coach pairs and assistance with setting up initial contact. In addition, coaches indicated positive feelings regarding improved teaching and mentoring culture within the department as well as positive reception to external incentives such as end-of-year coaching and mentoring awards that fostered a sense of appreciation for their role in the clerkship experience for students. Coaches also noted that high student engagement and buy-in re-enforced their own motivations to deliver high-quality coaching.

Discussion

Our study highlights both internal and external barriers and facilitators that were deemed influential in the implementation of an effective near-peer coaching program to enhance medical students’ HSS practice and clerkship learning in general surgery from resident coaches’ perspective. Overall, resident coaches perceived that the success of this near-peer coaching program centered around the continuous engagement of medical students, development of residents (coaches), and institutional and/or departmental team leadership and administrative support. These findings are consistent with current literature on near-peer coaching in UME [17, 18].

Overall, some coaches perceived that they were ill-equipped to assess and/or address clerkship students’ HSS learning needs due to internal challenges, including limited experience serving as an HSS coach as well as limitation with rapport and student engagement. A near-peer coaching program with a focus on students’ HSS practice is a new educational innovation emerging in surgical education. Few studies have been published to date. To facilitate the success of such programs, there is a need for clerkship directors to collaborate with residency program directors in developing formal coaching curriculum and promote interactive didactic sessions to equip resident coaches with the necessary skills to improve their coaching capacity and effectiveness.

Coaching has been shown to play a valuable role in medical education through enhancement of self-directed learning and self-awareness [19], both vital skills as medical practitioners. Several publications have focused on ideal factors in successful coaching relationships, including establishment of psychological safety, goal setting, and incorporation of feedback [19, 20], factors that were identified by residents in this study as well. Previous studies have shown that residents spend as much as 20% of their time in teaching [21], while medical students report that up to 40% of their learning comes from residents [22]. Although the ACGME (Accreditation Council for Graduate Medical Education) has incorporated the development of teaching skills for medical students and junior residents as a milestone for general surgery residents [23], teaching, mentoring, and/or coaching curricula are not universally integrated into residency training programs [22]. This deficit has prompted surgical societies such as the American College of Surgeons (ACS) to independently provide opportunities for formalized instruction to residents, exemplified by the annual ACS Residents as Teachers and Leaders course [24].

In this study, the American Medical Association (AMA) published guidebook “Coaching in Medical Education: A Faculty Handbook”[25] was used as a primary resource to facilitate the resident training process. Coaches were encouraged to focus on creating a collaborative coaching model with their student coachees to best support their development as self-directed learners. In such a setting, both non-directive language (methods primarily employed through probing and questioning students to assist them in increasing their awareness of their own goals and learning deficits) as well as directive language (where coaches impart information or feedback and share experiences with coachees) were used [26]. Self-determination theory acknowledges the independent natural motivations of individuals to learn and improve, but also recognizes the important role of coaches as a source for valuable change-oriented feedback [27,28,29,30]. Previous studies have shown that trainees often need support in performing self-assessment and that unguided self-assessment is often flawed as trainees most often tend to overestimate their performance [31,32,33]. In line with the findings of this study, others have also reported the importance of coaches being able to unpack and discuss disconfirming feedback within the coaching relationship. In addition, the processes of gathering external feedback, then internalizing and integrating this information into future practice can be heavily influenced by the source of the feedback and the setting in which this feedback is deconstructed and processed [34,35,36]. As learners advance through the 5 phases of self-assessment [35], the role of the coach can evolve and recent studies suggest that learners are most likely to better integrate feedback disparate from their own self-view when received from a trusted source [27, 36]. Similarly, our study found strong rapport building to be one of the greatest facilitators influencing coaching effectiveness from the resident coaches’ perspective.

When exploring barriers in coaching, residents noted that a student’s lack of interest in surgery and not being on the same surgical service (e.g., trauma surgery) with their student(s) were two factors that potentially prevented them from more effectively engaging with students. This most heavily affected coaches who reported limited meetings (i.e., < 3 meetings). Although intentional avoidance of matching same-service student-coaching pairs can help minimize potential bias on students’ academic grades, this can be eliminated by prohibiting resident coaches from providing formal evaluation for their assigned students. Alternatively, programs must weigh the risk vs potential benefits of allowing same-service resident-coach pairings, which may better enable residents to provide more authentic and timely feedback [37].

Finally, from an institutional level, resident coaches considered departmental support and recognition as two key facilitators of a successful and effective near-peer coaching program. Therefore, it is important for programs to invest in sustainable ongoing coaching incentives, such as an annual award recognition mechanism (e.g., Best Resident Coach Award voted on by students). In our program, residents who complete the coaching program receive certificates of recognition during the annual general surgery graduation program, and honorary awards are given to the two best coaches as nominated and voted upon by students. Finally, clerkship coordinators must provide consistent administrative support to offload residents’ administrative time commitments and increase clerkship students’ engagement in the coaching process.

Limitation

This study had several limitations including being limited to a single academic institution. Sample size of residents was limited to the size of willing participants within a medium-sized general surgery program and hampered by minor coach attrition from the program when residents were pulled to special service coverage plans during the COVID-19 pandemic-related hospital coverage disruptions. In addition, the scope of this study was limited to resident perceptions of the program. Research regarding the student perspectives is ongoing and will similarly incorporate surveys and semi-structured interviews conducted with a select sampling of students to understand student coachee experiences.

Conclusions

Effective near-peer HSS coaching by residents on surgical clerkships can be enhanced by good structural support, emphasis on coach training, a focus on enhancement of relationship building behaviors, and early goal setting with focused attention to the needs of the individualized learner. Our study found that rapport building and goal setting were the two most prominent factors in effective HSS near-peer coaching relationships. During the early phase of coaching, rapport building may serve as one of the greatest challenges for new coaches. However, during the late phase of the coaching, rapport can serve as a facilitator of long term-effective coaching in coordination with strong central program support.