Coaching for CBME: Lessons from sports and music

Competency Based Medical Education (CBME) can overwhelm. Its logistical considerations seem limitless. What IT platform will we use? How will we create reports for competence committees to consider? Where will faculty find the time to meet the increased assessment requirements? How can we adapt school policies to guide us effectively in this new reality? How and when should data about learner progress be shared with the certifying colleges? It’s easy to lose sight of the core values of CBME.

Fundamentally, CBME asks us to do three things:

  • Define the desired outcomes of our programs;
  • Coach learners to achieve – and ideally exceed – these outcomes;
  • Ensure trustworthy assessment that assures us, and the public, that our graduates are ready to enter unsupervised practice.

While defining outcomes and assessing learners has consumed much of the effort around CBME implementation, I think our ultimate success may depend more on whether or not we get the coaching part right. While the idea of coaching seems to resonate well with medical educators, the best approach to coaching remains a grey area.

In my research, I’ve asked what we can learn from the training of athletes and musicians. Sports and music are fields in which coaching looms large. Athletes and musicians find it difficult to imagine how they could develop their skills without their coaches or their music teachers. Yet in the ‘learning-by-doing’ world of clinical training, medical learners seldom attribute much of their professional development to their teachers. Why is that? What happens in sports and music that makes effective coaching possible?

Coaching demands meticulous, ongoing observation of learners. Athletes will tell you that a coach isn’t doing their job unless they are watching them and offering ongoing feedback. And if you ask musicians how often they receive feedback from their teacher after a performance the teacher didn’t actually hear, they can’t even imagine how that could be possible. But in medicine, we do it all the time — constructing feedback around partially or non-observed performances, and filling in the blanks with inferences that may or may not be accurate. This deficit needs attention if we are to coach medical learners effectively.

Coaching thrives on relationships of trust. Athletes and musicians tend to work with the same coaches over extended periods of time. They come to know and trust their coaches. Trust facilitates those tough conversations that coaches sometimes need to have with their learners. In medicine, though, longitudinal relationships between teachers and learners may be scarce. With a revolving door of clinical supervisors in some programs, establishing trusting relationships may be tricky. But without trust, the safety that the coaching relationship requires may be difficult to create. 

Coaching requires consistently meaningful feedback. To be meaningful, feedback should be timely, specific, actionable, and task-directed rather than person-directed. In short, it should be both credible (feedback the learner can trust) and constructive (feedback the learner can use). Feedback in coaching is an ongoing conversation between teacher and learner, a conversation that requires both participants to be continuously reflecting. Learners need to reflect on their own performance, identifying both what they feel good about and what needs to improve. Coaches need to reflect on their approach, identifying the strategies that work for this learner and those that don’t.

One more critical thing: sports and music coaches are very explicitly trained for their roles. Simply being a great performer won’t cut it. In most sports in Canada, even an Olympic gold medal as an athlete won’t qualify someone to coach. And in music, students know that the most transcendent performers sometimes make poor coaches.

Sports and music hold the best coaches in high esteem, and recognize that coaching demands a distinct set of skills that must be developed and honed over time. In medicine, though, we have paid little attention to training coaches — we’ve just assumed that great clinicians automatically make great coaches. Except sometimes they don’t.

Coaching, in short, requires a shift in philosophy. It isn’t about the finite exercise of teaching something to someone, but rather about the infinite exercise of continuous improvement. The best athletes and musicians trust in the power of coaching to push them to be better than they imagined they could be. Making room for coaching in medical education will require commitment – to observing learners, to fostering trusting relationships, to training coaches. The payoff may be immense. 

Dr. Chris Watling, MD, PhD
Associate Dean, Postgraduate Medical Education, Schulich Medicine & Dentistry