Imagine a pro quarterback stepping onto the field without his coach running pregame drills or a pop star taking the stage without vocal warm-ups. In sports and music, such last-minute preparation is generally nonnegotiable. Coaches review and refine performance, address weaknesses and ensure readiness.
Yet in medicine, where the stakes are often life or death, the idea of warming up with a coach before performing a high-stakes medical procedure is virtually nonexistent.
In a recent study conducted by us and others at the Harvard-affiliated Boston Children’s Hospital, we sought to assess whether coaching inexperienced clinicians within an hour of a procedure could improve their performance and, most important, their patients’ outcomes.
We focused on a procedure performed in the United States more than a million times a year: infant intubation. Intubation is a delicate procedure requiring the insertion of a breathing tube into a trachea or windpipe. Infants requiring surgery or those whose breathing is compromised by infection, premature birth or other causes frequently need intubation. The procedure is high stakes: A single error can lead to complications from low oxygen to cardiac arrest.
We studied trainees who had little experience with intubating infants: anesthesia residents, new fellows (physicians who recently completed residency and were pursuing advanced training to become pediatric anesthesiologists) and student nurse anesthetists.
We randomized these trainees into two groups. The first group received supervision from senior clinicians while intubating infants, which is routine. The second group — the “coaching” arm of the trial — also received supervision while intubating infants, but in addition, they got targeted coaching by a senior clinician within an hour of that intubation. This warm-up took only five to 10 minutes and involved the trainee reviewing and practicing on an infant manikin the steps required to intubate a baby safely.
Our findings were striking. Coaching inexperienced clinicians within an hour of intubating an infant significantly improved success rates. The coached group placed the breathing tube in the infant’s windpipe on the first attempt over 91 percent of the time, compared to nearly 82 percent in the control group.
Intubating a baby on the first attempt is a crucial patient safety metric. Infants are particularly vulnerable during intubation because the oxygen levels in their blood can rapidly fall, which creates time pressure and increases the clinician’s mental effort. Studies consistently show a higher probability of low oxygen with more than one intubation attempt, and respiratory events are a leading cause of brain damage and death, an important source of malpractice claims for young children.
Clinicians who received coaching within an hour of performing intubation could not only intubate infants on the first attempt more often, but the intubations proceeded more quickly and more safely. For example, coached clinicians reported improved ability to see the larynx, which predicts greater ease in placing the breathing tube in the right place. The coached group also reported significantly lower mental effort while intubating, which is vital because high cognitive strain while performing a procedure can increase errors.
While many studies show that the more procedures a doctor performs, the better their outcomes, what is less appreciated is that the timing of when that experience occurs also matters. One study of cardiac surgeons suggests that time away from the operating room can worsen surgeons’ performance. Training weeks or months before a procedure may be less optimal than receiving training days or, ideally, minutes before.
Our study serves as a proof of concept for what might be possible in medicine at large. Sometimes clinicians do a procedure only rarely, and their skill in it decays. Could a little coaching right before a procedure benefit surgeons for complex operations, emergency responders before a critical intervention, or nurses performing high-stress tasks?
Warm-ups with expert coaches are standard in music, sports and even military operations. Research suggests they sharpen focus, reduce errors and build confidence. Admittedly, integrating this approach into the fast-paced and cost-conscious world of medicine isn’t without difficulties. Critics may worry about the time required or the potential disruption to work flow. However, warm-up and coaching in our study took just minutes.
If coaches in sports and music can find time to fine-tune their teams and performers, surely the same is possible in medicine.
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