COACH, a New Way to Train Doctors

By Joseph Neighbor

While a resident at NewYork-Presbyterian/Columbia in 2004, James Lee, MD, started considering the implications of a law first passed in New York in 1989 then expanded throughout the United States in 2003 that limited a medical resident’s time in the hospital to 80 hours per week. Before 1989, it was not uncommon for residents to spend 100 hours or more in the hospital in a week, gaining experience and learning their trade through sheer volume and repetition.

“In the traditional, hands-on model of teaching medicine, whether or not you were overtly taught something didn’t matter so much, because you cared for so many patients that eventually you learned how to take care of people. This was learning through on-the-job training,” says Dr. Lee, now assistant professor of surgery at P&S. “With the new work hours restrictions, suddenly doctors were graduating with one-third less experience than previous generations, and experience is absolutely critical to becoming an excellent physician. I started thinking there must be a way to leverage technology to bridge that gap in experience.”

With the help of a part-time programmer and his brother, a software designer, Dr. Lee set out to design an education program that uses the latest technology to ensure that health care providers will have the requisite skills to practice medicine at the highest level.

COACH—Comprehensive Online Archived Care Heuristic—was the result of that hard work. The educational platform, which he describes as “the Wikipedia for medicine but with oversight,” is a learning management system that aggregates the latest medical information and techniques, which is then accessed via an online portal, collectedmed.com. Each discipline has its own “pod”—that is, voluntarily populated with content by the user community and edited by a panel of experts in that field to assure its accuracy.

“COACH is a multitenancy solution. The analogy is that COACH is like an apartment building: The common areas, the grass, the maintenance are all taken care of by the landlord,” says Dr. Lee. “But in the individual apartments, each tenant can choose the paint and furniture. COACH takes care of all the infrastructure needs and each partner has a pod that they can customize as they like. We hope to have a pod for every medical discipline. Of course, this model and platform can be used for any industry educational application.”

While a textbook can take five years to write and edit before reaching the student—by which time it is often out of date—COACH evolves in real time. Its versatility is one of its strongest attributes. Some partners, including groups at Columbia, use it as a learning management system while others use it as part of a “flip the classroom” approach, where learners gain foundational knowledge at home and apply it in real world situations the next day. Currently, 97 percent of general surgery residents nationwide use COACH through the American Board of Surgery’s SCORE curriculum. Other partners include the American Society of Breast Surgeons, whose breast surgery manual Dr. Lee describes as “the first wiki with oversight textbook,” and Heartsource, a consortium of heart-focused hospitals and groups across the United States.

Dr. Lee was prompted to create COACH while studying various theories of adult learning, including what is known as cognitive pre-training, a method used by NASA. In the case of medicine, a student using cognitive pre-training is instructed in everything he or she needs to know before interacting with patients; the hands-on work that follows focuses on building upon that bedrock of knowledge. According to a large body of research, cognitive pre-training achieves roughly two-thirds the benefit of actually doing a task.

But training the next generation of surgeons and physicians is only part of what COACH can do; given medicine’s rapid changes, even highly experienced doctors can benefit from a constantly evolving, updated body of information. “In this day and age, it’s impossible for one person to know it all, there’s just too much information. Yet in medicine, we still hold to the impossible ideal of a physician who is a walking encyclopedia of everything. This model just doesn’t work anymore,” says Dr. Lee. “Medicine should go the way of law. In law school, they don’t teach you each individual law, there’s too much of it. The primary focus is teaching you how to find the relevant law and applying it intelligently. In this new model, COACH would be the ultimate resource for finding the necessary medical information. By taking the learning curve out of the patient interaction, COACH is making medicine safer and more efficient.”