Tips for developing a coaching program in medical education

ABSTRACT

This article provides structure to developing, implementing, and evaluating a successful coaching program that effectively meets the needs of learners. We highlight the benefits of coaching in medical education and recognize that many educators desiring to build coaching programs seek resources to guide this process. We align 12 tips with Kern’s Six Steps for Curriculum Development and integrate theoretical frameworks from the literature to inform the process. Our tips include defining the reasons a coaching program is needed, learning from existing programs and prior literature, conducting a needs assessment of key stakeholders, identifying and obtaining resources, developing program goals, objectives, and approach, identifying coaching tools, recruiting and training coaches, orienting learners, and evaluating program outcomes for continuous program improvement. These tips can serve as a framework for initial program development as well as iterative program improvement.

KEYWORDS:

• Coaching
• program development
• professional development
• medical residents
• medical students
• program design

Introduction

Coaching is a versatile means to foster lifelong learning and has been identified as an essential tool for trainee education during medical school and residency [1]. As Deorio et al describe, the goal of coaching in medical education is, ‘to support a developmental process whereby an individual learner meets regularly over time with a faculty coach to create goals, identify strategies to manage existing and potential challenges, improve academic performance, and further professional identity development toward reaching the learner’s highest potential’ [2]. Coaching can improve trainee knowledge, skills, and attitudes [3]. In medical education, coaching programs for students, trainees, and faculty have demonstrated positive impacts on multiple outcomes, with real world examples including clinical competency, surgical skill proficiency, professional identity formation, and wellbeing [4–9].

As coaching becomes increasingly utilized in medical education and is endorsed by accreditation organizations [1], guidance for program development is essential to ensure the goals are achieved [10]. There is limited literature to guide educators in the development of a coaching program. Several of our authors contributed to a recent book on coaching in medical education which describes approaches to program development [11]. Building on this prior work, we created 12 tips that offer a structured approach, aligned with Kern’s framework for curriculum development [12] (Figure 1). These tips represent a review of the literature combined with our collective experiences implementing coaching programs for medical students, residents, and faculty at two institutions.

Figure 1. Integration of tips for developing a coaching program in medical education with Kern’s six steps for Curriculum development.

Reproduced with permission from Figure 1 of: Thomas PA, Kern DE, Hughes MT. 2016. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore. UNITED STATES: Springer Publishing Company, Incorporated. © 2022 Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press.

Tip 1

Identify “the why” or reasons a coaching program is needed

Begin by outlining the reasons, or purpose, for a coaching program at the outset to ensure a strong foundational underpinning. The purpose may come from national recommendations which call for coaching to improve the transition from medical school through residency to foster growth mindset, professional identity, self-confidence, and wellbeing (cite). As you move forward, the initial purpose you identify will both inform and be refined by each ensuing tip. Tip 1 aligns with the first part of Kern’s Step 1: Problem Identification [12].

To define your purpose, begin by reflecting on what problems or challenges you are facing that your current curriculum is not achieving. What fuels your desire to implement a coaching program? Who are your target recipients? For example, you may wish to enhance clinical skills for all residents [7] or remediate struggling pre-clinical students [13]. Consider how coaching can be integrated into or can supplement your existing educational programming.

Tip 2

Learn from established programs and prior literature

The growing body of literature in medical education provides the opportunity to learn from others’ experiences, successes, and challenges to inform your own program’s initial development [6,7,11,14–16]. Tip 2 aligns with the second part of Kern’s Step 1: General Needs Assessment.

Begin by reviewing the benefits of coaching, best practices for program development, and coaching principles, techniques, and approaches. Next, consider the learner group who will receive coaching and the area of focus. Partner with a medical librarian to identify all relevant literature. Supplement this literature review with conversations with trained and experienced coaches and established coaching program leaders.

For example, if you seek to develop a coaching program to foster technical skills, review the literature on coaching in general and on the expert performance of targeted skills (i.e., procedure checklists, entrustable professional activities, milestones, and established coaching programs that address technical skills). Consult with educators who have started similar coaching programs and consider using strategies such as review of objective data, learner reflection, and co-creation of learning goals and strategies with the learner. Use a similar approach if your program aims to address professional development, clinical skills acquisition, professional identify formation, or well-being.

Tip 3

Conduct a needs assessment of key stakeholders

A needs assessment helps you align the program goals and objectives with stakeholder needs, ensures buy-in, and identifies existing support structures. This tip aligns with Kern’s Step 2: Targeted Needs Assessment.

Stakeholders may include learners, coaches, hospital and departmental leaders, patients, and others. A needs assessment may include surveys, focus groups, interviews, or a combination of these methods. Baseline metrics from the needs assessment can be compared against follow-up data to evaluate the program. In addition, a needs assessment may uncover existing resources, such as mentors or funding currently allocated to a remediation program that could be reimagined into a coaching program with potentially broader impact.

Increasingly, medical educators are using co-creation to engage learners and other stakeholders in coaching program design and implementation. Co-creation is thought to enhance learner engagement and satisfaction as well as the overall quality of educational programs [17]. For example, learners and other stakeholders can help review the findings from the needs assessment to provide further perspectives on program development.

Tip 4

Identify and obtain resources needed

Resources needed may include funding to support new faculty coaches, a coaching director, an administrator, and faculty development, or to enhance existing programs and develop new skills for current mentors. Clarifying necessary resources based on your purpose and needs assessment (Tips 1–3) will allow you to advocate for resources throughout program development and scope your program for success within the confines of resources available. This tip aligns with Kern’s Step 5: Implementation.

In the business literature, the return on investment for executive coaching is estimated to be as high as 600%, attributable to enhanced skills, increased retention, and reduced turnover [18,19]. Highlighting this finding may motivate institutional leaders to allocate funding. Resources may come from a division, department or institution. For example, a positive psychology coaching program may align with an institutional goal of promoting clinician wellbeing, thereby justifying resources earmarked for this purpose.

Depending on the program’s scope and number of learners, coaching may require a significant amount of time. Ideally, coaches will have protected time (some programs have earmarked 1–2% FTE per learner per coach), or alternatively a financial bonus or stipend [7,20]. This support enables faculty to devote sufficient time to coaching and may increase the quality of coaches. A coaching director is important to serve as the leader of the program and guide faculty development and program improvement. An administrative assistant can support scheduling, documentation, and outcome tracking as well as assist with faculty development sessions. Different options for faculty development, described in Tip 9, vary in resources required.

If financial resources are unavailable but there is a clear need for coaching, we recommend identifying faculty with existing educational roles who can address the need by augmenting their coaching skills, such as by adopting a ‘coach approach’ within their work as educators rather than building out coaching as a distinct programmatic entity. We have successfully applied this method locally by delivering coaching training to program directors, advisors, mentors, and department chairs and by encouraging these leaders to utilize coaching [21,22].

Tip 5

Outline program goals and objectives

The next tip is about outlining the goals and objectives for the program and aligns with Kern’s Step 3: Goals and Objectives. The goals are the broader desired outcomes of the program and can be developed based on your initial purpose from Tip 1, now with more definition and scope based on your literature review, needs assessment, and available resources. Objectives are shorter-term, measurable actions that help accomplish the goals.

Examples of coaching program goals include enhancing professional development or wellbeing [6], improving clinical or technical skills [7], and bolstering communication skills [23]. Your goals should align with available resources and existing programs. If resources are limited, you may need to seek additional resources or reset your goals. For example, coaching for career development may be amenable to a short intervention, such as three coaching sessions [24]; a goal to support clinical skills development may require longitudinal coaching and additional resources. An important determination will be if coaching is purely formative for the learner, in which case the coach will not contribute formal assessment data to the clinical competency committee. The advantage of a purely formative approach is in fostering psychological safety between the coach and learner. In contrast, if coaching is both formative and evaluative, the coach will contribute assessment data to the clinical competency committee with the goal of improving assessment quality for learners. It may be easier to obtain funding for coaching that is both formative and evaluative.

Once the overall goals have been defined, they should be unpacked into specific, measurable, actionable, relevant, and time-bound objectives [25] that address knowledge, skills or attitudes. Bloom’s taxonomy [26] of educational objectives can serve as a guide. If you obtain pilot funding for your program, include measurable short-term objectives to allow you to demonstrate a return on investment early on.

Expect to revisit your objectives when you arrive at Tips 11 and 12, which address programmatic feedback and evaluation.

Tip 6

Design programmatic approach

This tip involves investigation of a conceptual framework(s) to lend structure to your goals and objectives from Tip 5. A conceptual framework can guide the program goals and approach to coaching interactions. Tip 6 aligns with Kern’s Step 4: Educational Strategies.

Frameworks which emphasize guidance through questioning are well-suited for coaching, as they are learner-centered. For example, coaching to develop lifelong learners might utilize the master adaptive learner model, whereby the coach guides the learner through the planning, learning, assessing, and adapting phases of knowledge and skill acquisition [27]. A coaching program for wellbeing may utilize the Framework for Improving Joy at Work or Positive Psychology [6,28,29]. The Stanford Pediatric Residency Coaching Program drew from reflective practice, lifelong learning, goal-setting and self-determination theory and developed a novel conceptual model for coaching in medicine as a cycle of continuous improvement [7,30–32]. Finally, consider Professional Identity Formation as a framework to help learners develop an identity as a physician and to embrace a growth mindset and self-determination to continue their ongoing professional growth [33]. Consider also Kolb’s Experiential Learning Cycle as a framework to reflect on and learn from concrete experiences and to experiment with future experiences [34].

Tip 7

Gather, adapt, or design tools for coaching

Educational tools provide structure and focus to allow coaches and learners to accomplish identified objectives. Selecting tools for coaching aligns with Kern’s Step 4: Educational Strategies.

The choice of tools depends on the goals and approach of coaching. Using Tips 5–6, boil down the coaching role to specific tasks to determine what tools are needed. Coaches may observe clinical or procedural skills and then facilitate reflection and goal-setting. Coaches may also guide reflection independent of observation, such as for career and professional development goals. Frameworks (Tip 6) can also be applied as a tool to structure feedback, such as the R2C2 framework which emphasizes the coach-learner relationship and the learner’s reaction when discussing feedback [15].

MedEdPortal (Washington, DC) and PubMed (Bethesda, MD) are valuable repositories for tools, and some specialties have an educational warehouse of shared materials. Try searching for ‘coaching tools’ or ‘direct observation tools.’ You can also look for tools at your own institution. Many academic centers have professional development or medical education departments. Alternatively, other coaching programs at your institution may have useful tools.

For example, many coaching programs include direct observation of clinical skills using tools to guide the observation [35,36]. If you cannot find any existing tools that meet your needs, consider adapting a tool from another discipline or creating a new tool. If you create a new tool, make sure you follow best practices for instrument development [37–39], and consider evaluating and publishing it for others to use.

Tip 8

Recruit coaches

Coach selection aligns with Kern’s step 5: Implementation. Begin recruiting coaches by writing a job description with an overview of the program, the responsibilities of coaches, the skills, experiences, and attitudes desired in coaches, and the benefits provided. Include expectations about the number of learners, coaching sessions, and required meetings, as well as estimated time commitment and duration of the position. Consider how a coaching role might overlap with other academic roles currently held by candidates and explicitly list leadership positions that may present a conflict of interest with coaching. Consider a statement highlighting the desire to recruit coaches from diverse backgrounds.

It is best to post the job description broadly to ensure recruitment of qualified applicants. An application may include a statement of interest, CV, any available teaching evaluations, and a letter of support from a supervisor. We recommend that a selection committee interview qualified applicants with structured questions to promote an equitable process and consider relevant skills including clinical and educational skills, emotional intelligence, and empathy. The selection committee may include multiple stakeholders, including learners who will be the recipients of the coaching program.

The selection of a cohort of coaches may be guided by your vision for matching coaches and learners. One example is to match a coach with a cohort of learners by level of training. You may instead choose to match by career interest or primary location of practice, both of which drive the selection of appropriate coaches. Matching coaches based on important identities like race/ethnicity or gender may be considered depending on the goals of the program, needs and preferences of the learners, and availability of faculty.

Tip 9

Design and implement faculty development for coaches

Coaches need faculty development to be effective in their roles, and thoughtful design of this faculty development, including the content, educational strategies, and implementation, is key to ensuring the quality and effectiveness of coaching. Designing faculty development aligns with Kerns’ Step 4: Educational Strategies and Step 5: Implementation.

Coaching is a discrete skill set related to, but distinct from mentoring and advising [7,40,41]. Without careful training in coaching, well-intentioned faculty may default to techniques they are familiar with, such as the more directive, advising nature of traditional mentorship. Faculty development should include the specific frameworks and tools of your program, as identified in Tips 5–6. Specifically, faculty development should review the goals and structure of the coaching program, coaching techniques and approach, tools utilized, and the ethics of coaching including considerations toward confidentiality, informed consent, and conflicts of interest. In addition, faculty development should review the training learners receive about coaching. Coaching techniques and approach should include creating an environment of inclusion and belonging, fostering psychological safety, understanding coaching versus mentoring, giving feedback, listening actively, and co-creating learning goals.

As coaches gain experience, ongoing faculty development may be informed by targeted needs assessments of individual stakeholder groups. Key topics in our experience have included appreciative inquiry, fostering reflection, guiding learners in goal-setting, and recognizing personal biases and using inclusive language to meet the needs of diverse learners. Faculty development sessions provide opportunities for both structured teaching as well as ‘peer coaching,’ where coaches share their successes and failures with one another and work through shared challenges [42,43]. Faculty development cadence may vary depending on the needs of your program. In our experience, a monthly or bimonthly meeting to learn together has been key to building a community of practice for coaches [43].

Lastly, despite recruitment of excellent and committed coaches, it is important to anticipate turnover of coaches. Consider repeating orientation sessions for new coaches and providing periodic refreshers for continuing coaches. You might record your original sessions for use in future orientations.

Tip 10

Create and implement an orientation for learners

It is imperative to engage and prepare learners for coaching in a way that parallels the training and expectations for coaches. This tip spans Kerns’ Step 4: Educational Strategies and Step 5: Implementation. Note that engagement of learners in other tips, including the needs assessment and co-creation of programmatic goals and structure, will increase learner buy-in.

First, define objectives for the learner orientation. These may include discussing the goals and objectives of the program, the structure of the program, psychological safety and trust, tools used, and a shared language for coaching. Define coaching as a partnership between coach and learner for formative growth and development. Introduce relevant learning theories to heighten learner engagement. For example, introduce experiential learning to encourage active participation, self-directed learning or self-regulated learning to promote goal-setting [44,45] and growth mindset and reflective practice to deepen metacognitive skills [30,46]. Orienting learners to the importance of learner accountability and co-creation of goals will increase the likelihood of coaching success.

When coaching involves observation and feedback, teach learners how to receive feedback effectively. To mitigate some of the discomfort of being observed, help learners understand the importance of direct observation and how it aligns with the highest levels of Bloom’s taxonomy [47,48]. Learner engagement with lifelong learning and growth mindset theories may increase feedback receptivity through emphasizing feedback for growth (assessment for learning) over evaluation (assessment of learning).

Tip 11

Gather feedback on the program to assess feasibility and acceptability and to guide program improvement

Program evaluation should include gathering structured feedback from various stakeholders for ongoing program improvement and to ensure it meets key stakeholder needs [20,49]. This tip aligns with Kern’s Step 6: Programmatic Evaluation.

First, decide when to seek feedback. Balance waiting a reasonable length of time for the program to get off the ground with obtaining data for early iterative improvement, such as 3–6 months into program implementation. Next, consider from whom to obtain feedback and what you are gathering feedback on. Casting a wide net to include diverse stakeholders is ideal but must be balanced against the time and energy investment required. Input from learners is essential and provides insights into the impact of the program on their experiences, attitudes, and self-assessed growth, as well as barriers and ideas for improvement. Gathering feedback from coaches can provide information about whether the coach role is fulfilling and feasible, thus facilitating coach retention. Input from departmental and programmatic leadership may provide additional perspectives and help ensure ongoing buy-in and support. Align the content of the feedback requested with your baseline needs assessment from Tips 1–3 and your goals and objectives from Tip 5 to determine whether stakeholders perceive that your program is meeting your initial goals [50].

Finally, decide on how you will gather feedback. Program evaluation surveys are a good means to gather data from a large number of people, whereas focus groups and interviews allow for more in-depth information gathering from smaller groups. In deciding on the format, you may want to consult the literature on program evaluation in general and for coaching programs [20,51,52].

Tip 12

Collect program outcome data to demonstrate programmatic impact

In addition to gathering feedback from stakeholders, collect outcome data for a program evaluation plan to guide further improvement and to codify the value of your program. This tip can be considered simultaneously with or following your efforts to obtain feedback toward programmatic improvement (Tip 11), and also aligns with Kern’s Step 6: Programmatic Evaluation.

Kirkpatrick’s model for evaluation provides a framework for measuring learner outcomes, and the outcomes measured should map to your program’s goals and objectives. The lowest levels on Kirkpatrick’s model are learners’ reactions such as satisfaction and self-assessed confidence and competence [53]. These lower-level outcomes are relatively easily gathered through the same mechanisms in Tip 11, and can provide valuable information about whether goals and objectives are met.

We encourage you to also endeavor measuring outcomes at higher Kirkpatrick levels, such as trainee behavior and performance, such as through direct observation or impact on patients. The multifactorial nature of patient outcomes and the difficulty of measuring such outcomes within a reasonable timeline are challenges. Possibilities to consider include assessing changes in patient/family ratings of learners’ communication, patients’ satisfaction scores, medication compliance, healthcare screening or vaccination status, or other measures depending on the scope of your program [54]. A prior study looked at a program aimed to develop physician communication skills and evaluated changes in patient assessment of physician communication [55]. In this study, clinicians were more likely to ask for patient feedback, however patient ratings of physician communication did not improve, possibly related to high baseline scores. Coaching program outcomes may also evaluate trainee recruitment, retention, perceptions of the learning environment, and long-term career outcomes, including retention in clinical practice.

In addition to learner and patient outcomes, consider evaluating the impact of the program on faculty in the coaching role. Prior research in coaching has found that being a coach increases faculty’s professional fulfillment and their sense of purpose and community [43,56]. Specifically, coaches learn new clinical and academic skills, grow in relationships and sense of belonging within medical and academic communities, and deepen their professional identities as educators, leading to increased professional fulfillment [56].

Return on investment can be evaluated through cost savings, coach retention, trainee retention, trainees’ long-term career outcomes including burnout and retention in clinical medicine, or other methods. Whatever outcomes you choose, use a rigorous approach and disseminate your findings so that other institutions can learn from your experiences.

Conclusion

Developing a coaching program provides an unparalleled opportunity to support learners in maximizing their development. The 12 tips presented here are scoped to help educators develop coaching programs with various goals and target learners. We encourage you to consider coaching for all levels of learners and with different areas of focus depending on learners’ needs. We have provided suggestions for developing programs based on various resource levels. Expect that iteration will be the rule rather than the exception and revisit these tips periodically to ensure a coaching program that, over time, is finely crafted to your local landscape. We anticipate an increasingly rich landscape within the literature as coaching spreads, with future directions including integration of technology into coaching and further building evidence for learner outcomes and return on investment.

Acknowledgments

The authors would like to thank Lars Osterberg MD, Monique Naifeh MD, and Heather McPhillips MD, MPH for their thoughtful review of the approach to this article and Mystique Smith-Bentley RN, MBA and the Office of Patient Experience at Stanford University for their championship of coaching programming. The authors would also like to thank: Thomas, Patricia A., MD, David E. Kern, MD, MPH, Mark T. Hughes, MD, MA, Sean A. Tackett, MD, MPH, and Belinda Y. Chen, MD, eds. Curriculum Development for Medical Education: A Six-Step Approach.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Rebecca Miller-Kuhlmann

Rebecca Miller-Kuhlmann, MD is a Clinical Associate Professor of Neurology, Associate Director of the Stanford Neurology Residency Communication Coaching Program, and Assistant Dean for Pre-clerkship Education at Stanford.

Marzena Sasnal

Marzena Sasnal, PhD, MA is a Senior Research Analyst at the Center for Research on Education Outcomes (CREDO) at Stanford University. She provides consultations on research methods and assists in conducting research projects, including evaluating education programs.

Carl A. Gold

Carl A. Gold, MD, MS is a Clinical Associate Professor of Neurology and the Director of the Stanford Neurology Residency Communication Coaching Program. He is also the Program Director for the Stanford Neurohospitalist Fellowship, and the Vice Chair of Quality, Safety, and Experience for the Department of Neurology.

Aussama K. Nassar

Aussama K. Nassar, MD, MSc, is a Clinical Assistant Professor of Surgery and the Director of the Stanford Surgery Residency Communication Coaching Program. He is also the Program Director for the Stanford Surgical Critical Care Fellowship Program.

James R. Korndorffer

James R. Korndorffer Jr. MD MHPE is Vice Chair for Education, Stanford Department of Surgery, Director of the Goodman Surgical Simulation Center, Director of the Surgical Education Fellowship and Associate Professor of Surgery at Stanford.

Sandrijn Van Schaik

Sandrijn Van Schaik, MD, PhD is a Professor of Clinical Pediatrics at UCSF. She is the Baum Family Presidential Chair for Experiential Learning, Simulation Center Director, Director of Faculty Development in the Center for Faculty Educators, and Vice Chair for Education in the Department of Pediatrics.

Andrea Marmor

Andrea Marmor, MD, MSEd is a Professor of Clinical Pediatrics at UCSF who practices at San Francisco General Hospital. She is a medical student coach and Director of Faculty Development for UCSF’s medical student coaching program.

Sarah Williams

Sarah Williams, MD, MHPE, ACC is a Clinical Professor of Emergency Medicine (EM) at Stanford. She is the Executive Director of the Coaching Office: Advancing Coaching in Healthcare and Medical Education at Stanford (“COACHME@Stanford”) and is an ICF-certified coach. She is also oversees the EM residency coaching program.

Rebecca Blankenburg

Rebecca Blankenburg, MD, MPH is a Clinical Professor of Pediatrics, Director of the Pediatrics Residency Coaching Program, Associate Chair of Education in Pediatrics, and Assistant Dean of Graduate Medical Education at Stanford.

Caroline E. Rassbach

Caroline E. Rassbach, MD, MA is a Clinical Professor of Pediatrics and the Pediatric Residency Program Director at Stanford School of Medicine. She previously developed the Stanford Pediatric Residency Coaching Program in 2013 and served as its Coaching Director.