Enhancing performance and well-being for surgeons: the science of life coaching
By Lilli Cooper and Kelly Ong

Life coaching has emerged as a powerful personal and professional development tool, particularly for individuals navigating high-stakes environments. Life coaching emphasises self-awareness, self-management and self-efficacy, including establishing desired outcomes, goal setting and developing skills and action plans to achieve them. It provides a supportive partnership that helps individuals achieve their full potential and thrive in demanding circumstances. Kelly Ong, the Urology News Trainees’ Sub-Editor, met with plastic surgeon and life coach Lilli Cooper to discover more.

Q (Kelly Ong): Could you tell us how you got into life coaching?

A: (Lilli Cooper): I always had a holistic approach to health and became interested in the psychology behind performance when I developed a performance anxiety tremor during training, for which I felt there was limited support. I later needed systemic cancer treatment during my training, and this widened my interest in how to optimise foundational health to support performance, and how to use energy and physiological resources as efficiently as possible. I trained as a coach to learn more about how to support individuals in learning about themselves, and to learn about motivation and behaviour change.

Q: How does an individual know when to seek coaching?

A: Coaching can help when there is a gap between where you are now and where you want to be. It is self-driven, so it is especially important that you are motivated to work on this through designing and then taking action to reach your goals.

Q: What does a life coach do?

A: A life coach holds space, asks questions, and holds up a mirror to help you (literally!) reflect. As you develop more awareness, you might identify self-limiting beliefs, establish what brings you joy, and identify stuck behaviours and patterns. A coach will also hold you accountable and champion your potential. Different life coaches have their own styles and different training but, fundamentally, they help individuals identify where they’re holding themselves back, and where they want to get to, tap into their potential, and make choices that are aligned with what they care about and support their growth and fulfilment.

Q: Can you explain the specific nature of surgery as a high-stress field?

A: Surgeons are considered high-stakes professionals as they operate in environments  where their decisions carry significant consequences. The pressures that they face can lead to stress, burnout, and diminished performance if not managed effectively [1-3]. Life coaching offers tailored strategies to optimise performance, manage stress, and cultivate resilience in these demanding roles.

Resilience training at an individual level has been criticised, especially in the context of a surgeon preventing burnout. Developed in isolation, it has been argued that requiring a surgeon to be ‘resilient’ takes away the inherent responsibility for work organisations to improve the working environment of surgeons [4,5].

Surgeons are expected to possess or eventually develop the capacity to cope with, and perform well under stress, usually through repeat exposure to stressful circumstances. However, research suggests that surgeons and medical students are no more resilient than the general population [6]. Surgeons were also found to have a high burnout rate (of up to 40% [7]), as well as psychiatric morbidity, depression; and suicidal ideation rates higher than the general population [8,9].

A younger age was identified as a risk factor for burnout [7]. Junior surgeons may not be as adept as their senior colleagues in managing and recognising the signs of stress and dysregulation and calming themselves down in acute settings [2,10]. The female gender in surgery is also associated with higher levels of burnout [7], which makes female surgical trainees a vulnerable group who may benefit from techniques to safeguard their well-being in their careers. Interestingly, though the ‘imposter phenomenon’ was first described in 1978 as “an internal experience of intellectual phonies, which appears to be particularly prevalent and intense among a select sample of high achieving women” [11], more recent studies suggest that it may be equally prevalent among men [12], and that there may be differences relating to ethnicity. Coaching may help to bridge demographic, trait and confidence differences between different surgeons.

Q: Could you tell me a little more about the types of life coaching that benefit surgeons in your experience?

A: In my experience so far, there have been three main reasons that surgeons have sought coaching:

1) Anxiety about work or performance

• Presentation: Intense worry about work leading up to, for example, an on-call or surgery, during the event itself, or rumination after the event. These ruminations may focus on surgical performance, management, complications, and relationships, for example with trainers.
• Tailored strategies: Addressing negative self-talk and substituting it with positive self-talk. Identifying areas to improve practical or clinical skills, setting goals, and optimising taking steps to improve confidence. Moving from focusing on a perfect outcome, to establishing the process that usually results in an optimal performance for that person and remaining in that process. Learning techniques to manage anxiety in the moment, such as mindfulness, as well as prioritising recovery, relaxation and general health outside work.

2) General life coaching clients

• Presentation: Feeling unfulfilled or unmotivated at work; forgetting why they are doing the job in the first place; poor work-life balance, a lack of joy, play or energy in life in general, relationship issues.
• Tailored strategies: A focus on fulfilment work such as establishing values and a sense of purpose, and using this to align choices at work, and outside it, with what is resonant for that person. Developing strategies to prioritise joyful aspects of life, and to reduce those which are less valuable, which often involves understanding old patterns of behaviour and learning to say no! Thinking about different ways to approach ‘stuck’ relationships or situations and making choices around this.

3) Specific stressor (i.e. exam / interview)

• Presentation: A lack of confidence, or anxiety around performance. Difficulty accessing factual knowledge on the spot. Previous unsuccessful attempts at the exam or interview. The desire to optimise revision efficiency, or to unlock maximal potential.
• Tailored strategies: Executive style coaching including goal setting, scheduling according to individual characteristics (such as chronotype) and situations, strategies including using implementation intentions, single-tasking, minimising distraction, and reward to support behaviour change. Strategies to convert chronic stress to interrupted acute, enjoyable stress, to enhance performance.

Q: How can life coaching enhance the performance of a surgeon?

A: When we are anxious or worried, our amygdala fires up, and we have reduced activity in our prefrontal cortex [13]. This limits our access to our executive function and affects our decision-making skills, as well as making it harder to remember facts. Coaching techniques can help with awareness around, and the modulation of, stress so that we can learn to regulate our autonomic nervous system.For example, when we recognise our personal symptoms and signs of stress, we can use different tools like breathwork or posture change to regulate ourselves [14], or mindfulness to create a buffer and give ourselves a powerful moment to reset and choose how we want to respond in a moment of crisis [15], a bit like pressing the clutch down when the engine is revving too hard. Another interesting perspective shift is to repackage the emotion that we associate with a particular situation or sensory input to one that is more resonant, for example, from stress to excitement, and this can help enhance our ability to perform.

Figure 1: Visual representation of the spectrum of performance and their factors.

Q: How can life coaching improve the well-being of a surgeon?

A: Surgeons often enjoy stress. Acute stress is good for learning and growth, and this can lead to feelings of fulfilment. However, distress and chronic stress are what affect wellbeing and performance and can be harmful to health [16]. Coaching can help with the recognition and awareness of circumstances that cause stress to individuals. These are not always the most obvious, for example, one cause of stress is called ‘cognitive dissonance’. Cognitive dissonance describes situations where your actions are not aligned with what you believe to be important or true. Coaching provides a forum to explore individuals’ values and beliefs, and to consciously and intentionally align choices to them. We can also work on ways to optimise balance, and techniques to break chronically stressful cycles.

Q: What is the difference between resilience training and coaching?

A: Resilience is the concept of ‘bouncing back’ after a negative event; coaching can support resilience but is not specifically targeting it. There is a spectrum from burnout at one end, to realising your full potential, at the other. Resilience training can hopefully protect you from burnout and bring you back to the middle. Coaching and training based around performance optimisation and anti-fragility (where negative events make you stronger) can shift you towards enhanced performance. Some key factors that can enhance performance and support resilience include foundational health through sleep, nutrition, hydration, human connection, alignment with personal values, and a focus on a growth mindset, including developing our relationship with failure, and focusing on optimalism rather than perfectionism.

Q: Do you think coaching can help in equality and diversity in training?

A: Yes, I do. We know that there are differences in training trajectories depending on individual attributes and situations. I believe that coaching could help to mitigate differences between people that result in differing confidence levels, due to demographic or trait differences, differences in experience or training, or less than full-time work patterns, which can reduce confidence due to reduced surgical exposure. Technical surgical skills training, for example through simulation training, has a potentially significant role to play here, of course. Non-technical coaching can also help by increasing individuals’ self-confidence, goal setting and scheduling to make the most of their opportunities. Developing optimistic mindsets and replacing negative with positive and confident self-talk can help individuals feel more confident to take opportunities and stretch goals and demonstrate task persistence which can translate to enhanced performance, and support training access, equality and diversity.

Q: Can you tell us a little about the science behind life coaching?

A: Life coaching is grounded in the principles of positive psychology, cognitive-behavioural theory, and goal-setting research. By fostering self-awareness, enhancing goal clarity, and promoting action-oriented strategies, life coaches can help unlock potential, achieve desired outcomes, and improve overall wellbeing. Recent studies have elucidated the neurobiological mechanisms [17] underlying coaching interventions, demonstrating their capacity to facilitate neuroplasticity, enhance self-regulation, and facilitate lasting behavioural change [18].

Anxiety can have a detrimental impact on cognitive function and decision-making [13], both of which are critical during surgical performance. This is not only in the immediate term, however; there has been evidence to show that chronic prolonged stress can affect the morphology and function of our hippocampus, prefrontal cortex, and amygdala [19]. Here are some examples:

1. Goal setting: Encouraging clients to set specific, measurable, achievable, relevant, and time-bound (SMART) goals. Research suggests that setting clear goals increases motivation, focus, and the likelihood of success [20].
2. Strengths-based approach: Helping clients identify and leverage their strengths. Research shows that focusing on strengths enhances self-esteem, resilience, and overall wellbeing [21].
3. Self-reflection and awareness: Facilitating self-reflection exercises to increase self-awareness and insight into one’s thoughts, emotions, and behaviours. Studies indicate that self-awareness is associated with improved decision-making, emotional regulation, and interpersonal relationships [22]. Metacognition is the ability to evaluate one’s thinking, and it is crucial in controlling our mental function, and ultimately objective performance [23].
4. Cognitive restructuring: Challenging and reframing limiting beliefs and negative thought patterns. Cognitive-behavioural techniques, such as cognitive restructuring, have been shown to reduce anxiety, depression, and chronic stress [24].
5. Action planning: Assisting clients in creating actionable plans with specific steps to achieve their goals. Research suggests that action planning increases goal commitment and implementation intentions, leading to greater goal attainment [25].
6. Feedback and accountability: Providing constructive feedback and accountability mechanisms to keep clients motivated and on track. Studies demonstrate that regular feedback and accountability enhance performance and goal progress [26].
7. Behavioural activation: Encouraging clients to engage in meaningful activities and behaviours aligned with their values and goals. Behavioural activation interventions have been found effective in treating depression and increasing overall life satisfaction [27].
8. Mindfulness and relaxation techniques: Introducing mindfulness practices and relaxation exercises to reduce stress, enhance focus, and promote emotional wellbeing. Research indicates that mindfulness-based interventions improve resilience, coping skills, and psychological functioning [28,29].
9. Gratitude and positive affirmations: Cultivating gratitude and encouraging positive affirmations to foster a positive mindset and enhance resilience. Studies show that gratitude practices are associated with increased happiness, optimism, and overall life satisfaction [30].
10. Boundary setting and self-care: Helping clients establish healthy boundaries and prioritise self-care practices. Research suggests that boundary setting and self-care lead to reduced burnout, improved work-life balance, and greater overall well-being [31].
11. Physiological regulation: There are various techniques which are understood to regulate physiological arousal in the moment to optimise performance, such as volitional breathing techniques, posture alteration and mindfulness [14,15,32].

Conclusion

As the demand for peak performance and wellbeing continues to rise in high-stakes environments, the role of life coaching is poised to expand. Future research may help garner more rigorous evidence for its effectiveness for surgeons, and translational impact to their performance and patients. Moreover, efforts to increase accessibility and diversity within the coaching profession will be essential to serving a broader range of individuals effectively.Coaching is not just remedial. There is always room to enhance performance and experience; and there is always space to feel better and be happier. It is not sufficient for surgeons to only acquire the surgical technicalities of a procedure. Our aim should be to attain the bandwidth to perform at our optimum under unpredictable stressful circumstances day after day; and yet remain well and fulfilled sustainably in our long careers. Hence, personalised good quality coaching should be available to anyone who wants it.

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