Coaching and the Master Adaptive Learner: Made for each other?

In a previous post about Coach as Leader, I referenced the 4-stage coaching model used by Robert Hicks in Coaching as a Leadership Style. This model, like many other coaching models, is essentially the self-improvement version of a PDSA cycle. The coach’s role is to facilitate that cycle by helping the coachee reflect on the current state, identify changes, set goals, and act on them.

This kind of personal improvement cycle plays a key role in the American Medical Association’s Master Adaptive Learner (MAL) conceptual model within medical education.¹ This model postulates the metacognitive processes, behavioral traits, and environmental factors that, when present, promote the learner’s ability to regulate their learning.² In other words, this model aims to describe what it takes for someone to take ownership of their own learning: figure out their gaps, fill them with the right information, and then self-assess their performance to see if those gaps are filled.

Given that these are both personal improvement cycles, it would seem intuitive that coaching would be an ideal fit for developing the Master Adaptive Learner. Indeed, one of the factors thought to be critical to the development of a Master Adaptive Learner is a learning coach.²

But then again…

Recent work has called this presumption into question. Investigations of both MALs and non-MAL learners in GME have found that coaching has not been important to the learning practices of these learners.^3,4,5 Specifically, in their study of Master Adaptive Learners (MALs), Regan et al. found that none of these MALs reported ever using a learning coach.^3,4 I led a complementary study of non-MALs (i.e., MALs were excluded, leaving behind a group of typical resident physicians) for my MHPE thesis, and none of these residents reported using a learning coach either.⁵

So what gives?

It is important to remember that, while the MAL model is built upon a strong theoretical foundation, no empirical study was performed on learners to validate whether these factors are important before proposing that they were actually important. And, indeed, upon later attempting to create an instrument to quantitatively measure MAL skills, the creators of the model struggled to capture all of the proposed domains, characteristics, and phases of the MAL model (Stringer et al.).⁶

The good news is that the same work that questioned the value of coaching for MALs also found validity evidence for some of the proposed MAL traits/influences (e.g., curiosity, growth mindset, motivation, and the learning environment) while identifying some new ones (e.g., management of emotions, the importance of teaching, productive struggle, etc.).^3,4 So, perhaps the MAL conceptual model has value, but coaching isn’t actually one of the truly important developmental factors?

A whirlwind review of literature in support of coaching

Before we simply abandon the value of coaching to Master Adaptive Learners, it would be helpful to do a lightning-fast review of the demonstrated positive outcomes of coaching in medicine. Coaching has led to improved learner self-reflection and teaching effectiveness,⁷ resident goal-setting and reflective capacity,⁸ resident development of adaptive expertise,⁹ faculty professional identity formation and career planning,¹⁰ and reduced faculty burnout.^11,12 As you can see, these studies assessed different populations, so there may be limits to transferability – but there clearly are demonstrated benefits to coaching.

Squaring the MAL coaching circle

Let’s see if we can make sense of this literature supporting coaching and questioning its value to MALs.

1. More work is needed: Ah, the classic academic hedge! But seriously, only one group of actual subjects identified as MALs has been studied,^3,4 and the objectives were to evaluate (1) how the MALs plan for learning and (2) how the experiences of MALs can be utilized to improve the learning environment for all learners. Neither study directly assessed the value of coaching. It would be wildly premature to rule out the value of coaching at this stage, but as Regan et al. noted, the value of coaching to MALs is ripe for investigation.
2. Coaching is still novel/unavailable: Coaching is a new concept in medical education, and many learners in the studies by Regan et al. & Branzetti et al. may not have been in a program that provided coaching. This echos the point made in a prior post about Understanding the Many Forms of Professional Relationships: if you don’t know coaching exists, it’s unlikely that you will use it or appreciate its value.
3. Community coaching: Without widespread availability of coaching programs, GME MALs seem to assemble their own network of trusted resources for information, clinical advice, and career assistance. In a sense, MALs use an organic and ad hoc “coaching by community.” This is an interesting conceptualization of coaching that I have not come across before, and hopefully could be fleshed out (or disproven) by a well-performed investigation of coaching in MALs, or GME-overall.
4. Leading the horse to water: One of the fundamental goals of coaching is to help the coachee develop self-efficacy to take the initiative and make a change. Typical coaching relationships are initiated by a coachee after something has prompted them to independently acknowledge that a change needs to be made, and that they need help making it. UME/GME coaching, by comparison, is an assigned relationship that may simply be seen as a checkbox to fulfill rather than an exercise in developing self-actualization. Skilled coaches certain cultivate motivation and self-efficacy within the coachee, but I genuinely wonder if assigned coaching systems will have the same impact if the coachee hasn’t yet come to the conclusion on their own that coaching is valuable.
5. Nature vs nurture: From a far more philosophical perspective, it’s unclear if MAL characteristics are intrinsic to the learner or if they can be cultivated, practiced, and refined like, say, history taking or effective communication skills. If the skills are inherent, then perhaps MALs already have established high-quality learning skills when entering training and actually won’t benefit much from coaching. If they are able to be acquired, then MALs could still benefit from coaching to keep refining their already-impressive skills, and non-MALs could really benefit from coaching to help catalyze their transformation into MALs.

My Takeaway

As a coach writing a coaching blog, I have a wee bit of implicit bias favoring coaching. At the same time, I’m a member of the authorship team that identified the questionable value of coaching for MALs/GME learners. Do those cancel out? Who knows, but I do think there is clear evidence of the positive effects of coaching overall.

I will say that I was fascinated by the organic, ad-hoc coach-like community the Regan et al. MALs seem to utilize in their learning. I’d love to see this investigated along with coaching overall in MALs/GME learners. I’m also very curious about the nascent emergence of coaching programs in UME/GME – can “assigned” coaching programs truly work if the coachee hasn’t undergone the necessary self-reflection and actualization to seek a coach’s help? I’m looking forward to seeing the results of the AMA-funded NYU Transition to Residency Advantage program that does exactly this.