A Little Wisdom I Wish I Had Known When Leaving Medical School: Teams and Teamwork

I had been a resident for 4 years, and was an attending for 2 years before I started to talk to our teams about being a team. Anchoring, one of the cognitive biases, had struck. The way medical teams practice is “the way they should practice” — right? When you start at your institution, when it is new and fresh, your eyes are open. You look around a little for “some more data” but confirmation bias quickly kicks in: “Yes! This must be the way”.

What we need to practice is awareness of and vigilance against this happening in our clinical diagnoses, and also as we participate in, and yes even perpetuate, the systems of care. Sometimes you will be lucky, and stumble across work by others; you will be able to see new data, recognize it, and realize that there many other possible solutions or diagnoses, or even, ways to practice.

Luckily I stumbled across the Institute of Medicine (IOM) report on “Core Principles and Values of Effective Team-Based Health Care”, and then “What Google Learned From Its Quest to Build the Perfect Team”; and all of a sudden, I realized that so many others were thinking and rethinking how we work together — something we will do every day of our professional lives, with our families and in our communities.

So I started talking to my teams about being a team. I cannot share with you the perfect team structure, or the perfect way to collaborate. I don’t think there is a single perfect answer but rather that adjusting to the local context and unique team composition is needed. I do however think that there are foundational building blocks of good teams, and good team structures, and ways to tell when things are not working well. So I would like to share with you what I discuss with any new team that I work with, things that I think have helped us to take better care of our patients and each other.

First, as a team we talk about a few highlights from Project Aristotle at Google (I don’t do it justice here, so I recommend at least reading the review article in the references):

in teams, think about collective intelligence, which is almost always greater than individual intelligence.
there is no single team structure that is superior — highly structured leader-driven teams can do well or poorly, and non-structured teams can do well or poorly.
improvement in teams comes about by understanding and influencing group norms, and two factors seem to be key:
1. “on good teams, members spoke in roughly the same proportion”
2. “the good teams all had high ’average social sensitivity’ ”

So choose the team style that best suits the team, be open to everyone’s perspective and contribution (let everyone speak in equal proportions), and be sensitive to each other (protect team openness).

Second, we talk about the five attributes of highly effective teams that the IOM discussed in their position paper:

Shared goals — that must include the patient and their family. This last point is critical. Especially in inpatient medicine, the team sadly often excludes or treats merely as subject the patient and their family — don’t let it. I encourage everyone to ask the patient and their family what theirgoals are for today, and what their goals are for the stay. In primary care, I try to ask about longer goals and capture those, and always try to ask “if there was one thing I could fix for you today, what would that be?” I let everyone on our team know that I will ask them about their goals for our team today at the end of our discussion.
Clear roles.
Open Communication.
Mutual trust (and mutual respect).
Measurable process and outcomes.

At the end I ask everyone for their goals for today, and then share my goals. I think about these goals each time I come into the hospital in the morning, and they are both my promise and what invigorates me.

My goals are almost always — in this order:

To take the best care we can of the patients and families whom we serve;
To have a clearly communicated plan of care for each one of our patients;
To all learn something.

I have found the first goal to always be the primary goal for every clinician I have worked with — even though it is often not the first goal they state. It can seem like a truism, but it matters that it is stated out loud. It is the one which matters most to remember, and it is the one that will sustain you through the long hours.

If I have some wisdom to share, it would be this last point — know your shared goals, which must include the patient’s and their family’s goals. Remember them, talk about them, and let them ennoble you and your team. They will inspire you to be the best doctor you can be for the patients whom you are privileged to serve.

Medicine is not merely a job, it is a deep calling, maintained by will, deliberately strengthened by study, reinforced by practice, and sustained by the grace of caring. (Modification by NC of proverb on love)

This was previously published on Medium on 7 Dec 2017.

References

Mitchell P, Matthew W, Golden R, McNellis B, Okun S. Core Principles and Values of Effective Team-Based Health Care. Institute of Medicine. 2012.
Duhigg, Charles, What Google Learned From Its Quest to Build the Perfect Team, New York Times, 02/25/2016