Maintenance of Certification, Aging, & Our Patients

An article published in the Harvard Business Review set out to answer the question: “do doctors get worse as they get older?” With an aging population of physicians and the ever-changing nature of technology and medicine, it’s important that physicians maintain their clinical skills as they age. So what’s the best method for making sure that happens? We consider our options and make a suggestion in this blog article.

Current Standards

First off, let’s talk about the standards that are currently in place to ensure physicians keep up with the changing medical landscape. The American Board of Internal Medicine requires Internists to pass Maintenance of Certification (MOC) exams every 10 years in order to maintain their board-certification. Almost every surgical specialty has a different process for monitoring or mandating continuing education, certification, and tracking competency. But many are concerned that these assessments are not the best way to incentivize physicians to keep up with the latest technologies and improve patient care. Some have suggested a better way would be to measure patient outcomes. From the article:

“While there is some evidence that physicians’ clinical knowledge, adherence with up-to-date standards of care, and performance on process measures may wane as they get older, little is known about whether and how age impacts physicians’ practice and their patient outcomes.”

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Improving Performance & Outcomes

Even the methods for measuring our performance and outcomes is heavily debated. While it has not been well studied or reported on historically, patient outcomes have been shown to drop as a physician ages. There are many potential reasons for this, including:

  • It may be that many of us have difficulty adapting to change and older physicians may be last to adjust to advancements in technology.

  • It may be that some technical skills decline with physical decline, aging and mental processing delays, and each of us reaches a different tipping point where knowledge and experience overcomes these changes.

  • It may be that there are biases in the way the studies are performed.

When we go beyond understanding concepts of performance improvement as well as performance decline, my belief is that both are ideal for coaching. In many ways, we know ourselves best. We know the inner workings of our thoughts, feelings, and bodies. In other ways, coaching principles encourage one to receive constructive feedback, challenge thinking, ask empowering questions, and improve empathy in a more confidential and less judgemental environment. When you combine the expertise of a well-trained surgeon with that of a well-trained coach, the opportunities to improve and grow almost become endless. Whether early or late in one’s surgical career, most of us explore how and in what capacity we can apply our knowledge and skills to the benefit of ourselves and others.

What if our surgeons had coaches?

What if we used coaches to assist us to maintain and/or improve our skills?

What if coaches improved patient care, outcomes and experience?

SurgeonMasters is a physician coaching company delivering strategies tools aimed at preventing burnout and promoting wellness in the medical community. Have a suggestion for a blog article or podcast episode? Email us to get involved!

How HPDE Helps Me Be a Better Surgeon

This guest blog was written by Dr. Lora Melman.

My journey for continual learning started in medical school and pushed me through my surgical training. It didn’t become fun for me, however, until I discovered the sport of HPDE (High-Performance Drivers Education). Many of the tenets of HPDE can be directly applied to surgical practice. In this article, I’d like to walk through some of those connections and how HPDE helps me in my daily quest to become better as a surgeon.  

What is HPDE?

HPDE, or High-Performance Drivers Education, is a driving sport that teaches awareness, car control, and how to approach “the limit”— the limit of what-physics will-allow-that-car-to-do-at-that-particular-part-of-the-racetrack-on-that-lap-on-that-day. The focus of HPDE is to learn your car, the racetrack, your personal limits, and to maintain the flow of traffic around the track.

HPDE is an extreme sport that requires preparation, concentration, the ability to maintain calmness, and a level of skill to maintain the margin of safety. Novice drivers are required to have an instructor until they are judged safe enough to go out on their own.

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Big Vision

The most important thing I learned on my first day of driving school was to always look farther ahead than I thought I needed to, so that I would have time to appropriately modify my inputs. By the time something is right in front of you, it’s too late to react—by looking as far ahead as possible, you can still see everything immediately in front of you and also see the important reference points coming up so there is no lost input information.

Anticipating and “looking” ahead is something we talk about in surgery all the time. From the initial “time-out”, to OR cards that detail to the room staff what to open and what to have available, to anticipating needs to minimize chaos in the room and staff turnovers during critical portions of the case – the list goes on. Seeing what may arise while progressing through the immediate steps of the case increases efficiency, reduces unnecessary delay under anesthesia for the patient, and leads to improvement in overall outcomes and productivity.


Being out of surgical training for several years now has taught me the value of ongoing mentorship, especially in a field where techniques, materials, and technology changes so rapidly that within a few years, things can go from cutting edge to almost obsolete. In residency, my mental “bandwidth” was so fully occupied with learning surgical management and memorizing exactly how each attending did each procedure, that I didn’t pay attention to how my skills were changing and growing. Now that I am in practice, although I am eternally grateful for the excellent training background I received, there are days when I wish I could intraoperatively “Face-Time” one of my mentors to pick their brain about a no-way-to-predict-this-question-preop-haven’t-seen-this-before-what-they-would-do-now-in-this-particular patient-regarding-this-particular-issue question.

Learning to Drive Solo

After I graduated from novice HPDE group, I drove in Intermediate Solo (no instructor), and now am in Advanced Solo. There are many times I wish I still had an instructor in my right seat for immediate feedback for what I could have done differently. Sometimes I wonder what pearls I’m missing out on, yet 100% instruction at the upper levels of training is something that is just not realistic and/or achievable for the majority of participants in the sport, so we do our best, and try to set our own goals for improvement. Just as I am not done learning new things on the racetrack, I am continually learning new things as a surgeon.

I am one that believes there is no such thing as “natural inborn” talent, but rather that talent is the result of the right combination of personal drive to be better, willingness to work hard and push through difficulty, and an accumulation of previous skill “programming”. Deliberate slow practice of the sub-components and the process of mindfulness in repetition builds the circuitry that allows a tennis champion to predict where the ball is going to be, a musician to sculpt their performance, a race car driver to achieve a successful overtake, and a master surgeon to see the proper plane(s). The ultimate challenge, then, is to develop the correct skill set for the intended goal with the best possible mentorship available, and to maintain an insight on your own progress.

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Dr. Melman is a board-certified minimally invasive and robotic surgeon with a private practice in Central New Jersey. Her areas of expertise include Fast-Track Surgery/ERAS—the methodology of improving surgical outcomes and decreasing postoperative recovery times, repair of all types of abdominal wall hernias, sports hernias, and diaphragmatic hernias, treatment of reflux disease, and surgical weight loss for obesity. She is a widely published author of peer-reviewed literature on hernia mesh and biomaterials. She also has a special interest in studying safety, performance, and team dynamics based on principles used in the motorsports-racing world. Dr. Melman's series: "Surgical Lessons from the Racetrack", runs weekly during the summer season and explores the overlaps between the art of Surgery and the science of High Performance Driving.

The Hook Model and the Power of Coaching

Note: this is part 4 of our ongoing series on Habits & the Power of Coaching. Read part 1 here, part 2 here, and part 3 is here.

In the fourth and final installment of this series, we examine the Hook Model, created by Nir Eyal.

The Hook Model

In his book, Hooked: How to Build Habit-Forming Products, Eyal outlines the Hook Model, in which he explains why we habitually use certain products over others. There are four steps to the Hook Model:

  1. Trigger. An internal or external prompt to perform a certain behavior. Facebook initially triggers you with notifications to open the app, but eventually, you begin to associate using it with internal triggers, like boredom or anxiety.

  2. Action. A simple click, a tap, some scrolling, or whatever gets the user to interact with the product.

  3. Reward. Finding a funny video in an otherwise boring feed gives you a little dopamine hit. Varying rewards at different times make us curious and spark a desire to come back — over and over again.

  4. Investment. Now that you’re happy, companies ask you for something in return: time, data, and money are some examples. Ideally, you’ll even load the next trigger yourself, for example by commenting on a friend’s photo, to which they’ll surely reply and get you to come back.

Applying this framework to our own lives, we can get a better understanding of the products and services we’re addicted to (even though we may not even realize it).

  • If you find yourself mindlessly scrolling through Facebook several times a day but you’re not sure what brought you there… You may be hooked.

  • If you find yourself scrolling through your preferred BREAKING NEWS website 30 minutes after the last time you checked in on the world… you may be hooked.

  • If you find yourself curating your Instagram feed instead of preparing for your next important case… you may be hooked.  

Staying connected with friends and family. Being informed about our world. Partnering with influencers to share a message. We can find positives in most of the things we do. However, if the activity is distracting you from being productive in other areas, then there might be an opportunity for improvement. The trick is to identify and eliminate the trigger for this addiction. In an April 2018 blog SurgeonMasters contributor Jonathan Cabin detailed several strategies that can help us eliminate the action once we have identified our trigger.

How Coaching Supports the Hook Model

Bad habits are easy to come by, and difficult to break. Coaching can support, or more appropriately break, the Hook model in two important ways. One way coaching breaks the Hook model is by raising awareness around our triggers, actions, and rewards. It can be difficult to identify why we engage in a certain behavior, but this is an important first step in eliminating any habit. Coaching supports the process of guided inquiry and goal setting.

Why are we engaging in this behavior? What “need” is it fulfilling? If we can identify our internal triggers then we can take the next step.

Our next step is to terminate the action. Coaching supports this process of action planning and even constructive feedback on our actions. Is there another action we can take when we feel compelled from boredom to check out our timeline? Can we structure the action to create a similar reward or a proactively determined alternative reward? If we are able to identify our trigger and adjust the action, we are on our way to breaking the model and eliminating the habit. Of course, this is much more difficult than it sounds. With the assistance of a coach we flatten the learning curve.

You can learn more from Nir Eyal online, Resources for Hooked: How to Build Habit-Forming Products.

Harnessing the Power of Surgeon Coaching

Not everyone is ready or wants to work with a coach as there are very few examples of this in medicine. Most professional talents work with a coach (or coaches) on a regular basis to get to and stay on top. Surgeons can work with a coach (or coaches) to maximize their physical, mental, and even emotional skills. Working hand-in-hand with a coach can significantly increase your ability to create and maintain healthy habits. At SurgeonMasters, we offer coaching services to surgeons in all specialties. Let us help you create healthier habits and a more lifestyle-friendly surgical practice.

Want to learn more about surgeon coaching, perhaps to do a little of this rewarding activity on the side? Sign up for our inaugural training program on January 20, 2019 at the Kona Kai Resort & Spa in San Diego.

The Four Tendencies and the Power of Coaching

Note: this is part 3 of our ongoing series on Habits & the Power of Coaching. Read part 1 here and part 2 here.

In the third installment of this series, we examine The Four Tendencies, created by Gretchen Rubin, for creating habits. Gretchen is a four-time New York Times best selling author of The Happiness Project where she spent a year thinking about happiness and setting up networks of like-minded people pursuing happiness. Her work focuses on habits and what makes people happy.

The Four Tendencies

Before we get any further, let’s briefly outline The Four Tendencies framework. In this framework, Gretchen describes four types of people, broken down by how they respond to expectations (both inner and outer):

  1. Upholders. Upholders meet inner and outer expectations readily. They love rules, always have a clear plan, and are self-motivated and disciplined. They struggle in an environment that lacks structure.

  2. Questioners. As skeptics, questioners meet their own expectations, but resist outer ones. Questioners need to see purpose and reason in anything they do. Clarity as to why they should do something is all-important.

  3. Obligers. This is the most common type. Obligers love satisfying other people’s expectations, but struggle in prioritizing their own. Being held accountable by a friend, coach, or boss helps them a lot.

  4. Rebels. This category defies both inner and outer expectations. Freedom to choose feels most compelling to rebels. They want to be challenged, but not pressured into doing things.

If you’re interested in seeing which category you fall into, take this short quiz.

When it comes to creating new habits or changes in old habits, it is helpful to know how we respond to inner and outer expectations. When you understand which category you fall into, you can adjust your environment to better suit your tendencies. This process of reflection bearing out awareness is the first step in creating any habit.

How Coaching Supports the Four Tendencies

Personality tests are often scrutinized because our personalities can change over time. I also believe our personalities might change depending upon the situation. Therefore, the reproducibility of the test can vary depending on the surrounding circumstances. Ultimately, the purpose of using a personality test for habit change is not to give someone a label. It is to create an opportunity to explore whether incorporating the strategy increases your likelihood of success. If it works for you, this is a powerful tool! If it doesn’t, we cross this off the list and try another resource.  

Let’s look at physicians as an example. Most physicians fit the tendency of Obligers. As an Obliger, habits that relate to better service to others tend to be much easier to implement. If it creates efficiency and better patient care, the rewards are fantastic. However, the Obliger struggles to meet internal expectations. Being held accountable from a close colleague or coach can increase the odds of success for creating those healthy habits that seem to impact the Obliger most. It can also be very helpful to show the Obliger why the seemingly selfish habits are in fact unselfish because they meet the outer expectations of their friends, family, and patients indirectly (especially over time).

Take this The Four Tendencies Quiz and then consider how this might impact the most effective way to end old habits and begin new habits that are positive and create sustainability. We invite you to mail us what you found out! What is YOUR tendency? Did you reinforce what you already thought? Or was it different than you expected? Let us know your habit change, motivations, situational factors, and how it is going for you. Our team will follow-up with coaching questions to aid your self-inquiry. Your comments in private or on social media will also add to the conversations that we all need to be having.

Harnessing the Power of Surgeon Coaching

Working hand-in-hand with a coach can significantly increase your ability to create and maintain healthy habits. At SurgeonMasters, we offer coaching services to surgeons in all specialties. Let us help you create healthier habits and a more lifestyle-friendly surgical practice.

Want to learn more about surgeon coaching, perhaps to do a little of this on the side? Sign up for our inaugural training program on January 20, 2019 at the Kona Kai Resort & Spa in San Diego.

A Novel Idea for Safety, Productivity and Less Stress

Sometimes the key to peak performance isn’t rooted in rigid discipline, trendy gadgets, or the latest app.

Sometimes the key to peak performance is a service or technology uniquely applied to a surgeon’s life, like the one my mentor, colleague, and fellow orthopaedic surgeon Dr. Richard Santore applied a few years ago.

His application? — Hire a Town Car service to drive him to and from work Monday through Friday.

Hire a Town Car?

OK—technically the idea isn’t Dr. Santore’s (he borrowed it from a few of his joint replacement friends in NYC and LA) but considering Dr. Santore is the one who brought it to my attention, I’m going to give him the credit.

Now, I wholeheartedly realize how pretentious this sounds.

Paying $900 per week for a car service, Jeff? Are you CRAZY?! You think THAT is a good idea?

But the truth is…it is a great idea for some surgeons.

Allow me to explain, as Richard explained to me...


In the day-to-day life of a surgeon, time is precious and every free minute sacred.

The more tasks you can take off your plate—tasks that really don’t need your attention or expertise—the more effectively you can focus on the things that do require your talents.

By outsourcing the responsibility of driving to a professional whose sole purpose is to get from Point A to Point B safely, Richard reduces the risks associated with commuting (speeding tickets, car accidents, sensory overload, and undue stress) to a minimum.


Driving to and from the office or hospital every day in heavy traffic isn’t a pleasure—it’s a pain.

A gauntlet of fast cars, untimed stop lights, honking horns, bicyclists, and pedestrians you must carefully avoid in order to get to the place where your actual skills as surgeon are put to use.

Instead of waking up every day to curse the impending commute, Richard smiles knowing he’ll be able to catch up on the news with a cup of coffee, take phone calls, check his email, and get valuable consulting work done while somebody else handles the driving.


Since his one-way commute time is about 35 minutes, Richard spends 70 to 80 minutes in the car every day. With someone else handling the driving, there’s a lot he gets done in that time.

Besides, Richard has more consulting work to do than he can handle, and his hourly billing rate—$700—more than offsets the expense of the car—$85 including tax and gratuity for one-way to the hospital and then his office one mile away.

Imagine having a ‘really good stock broker’ who could take a $200 investment and give you $500 return daily—that’s what the car service is to Richard.  (His billed time $700 - $200 cost = net $500 or 250% return)

The car service isn’t an expense—it’s an income producing investment, with the car doubling as a WiFi-ready, mobile office.

And when the traffic is bad, he gets even MORE work done!

Expand Your Schedule

So, if you’re a surgeon looking for a creative way to expand your schedule, consider hiring a car service to handle your commute. Look at the operating expenses, cost savings, and planned revenue.


PS—Have your own creative way of freeing up time and getting more work done? Email me at to share your story.