Teamwork: The Challenges of Getting it Right
Although modern medicine can now offer patients much more, we need increasing numbers of doctors, nurses, and allied health care professionals to deliver it1. There is an intricate chain needed. It involves the decision to perform a medical investigation, the carrying out the investigation, its interpretation, the communication of the findings with the patient, and the initiation of therapy. When it all goes well the systems are very effective, but when it doesn’t it’s difficult to identify where the problem lies. The essence is teamwork and the degree of synergy between the individual members of the team. The concept was developed in the 20th century and has continued to grow. Teams are defined as two or more people who interact dynamically towards a common goal. The role of effective teams is of increasing importance because of rising co-morbidities, more chronic illnesses, shorter working hours and global staff shortages2. Commonly encountered medical teams are labour wards, ICUs, medical wards, and surgical units. An example would be a pregnant mother with diabetes and pulmonary embolus. She requires the services of obstetrics, endocrinology, and respiratory medicine.
As a medical student the priorities are one’s individual performance and success. When one qualifies and commences work, the new direction is teamwork and being an effective part of the team. This requires a significant recalibration. The undergraduate curriculum does not prepare the student for this major adjustment. The reasons are understandable. In undergraduate training the emphasis is on the basic sciences, clinical diagnosis and therapeutics. In the workplace there is an additional component, the quality and safety of patient care. The challenge is how to provide high quality care within a structure that is traditionally focused on personal achievement. Individuals have to be thought how to work as a collaborative.
A term being increasingly used is crew resource management (CRM). This concept promotes the shift from an individualistic culture towards a shared responsibility using all available resources including information, equipment, and people. One of the important tenets is situation awareness. In particular whether the common eventualities are being catered for. In the case of ill patients, it is important that the necessary staff, equipment, theatre, and ICU resources are in place in the event of a further deterioration.
Team performance is variable. It varies from department to department and from hospital to hospital. Factors that adversely affect good team work include the quality of communication. Breakdowns in coordination lead to errors. Mistakes also happen when an individual, undertaking a critical task, is interrupted by a staff member about another matter. A common scenario is when a patient’s medication dosage is being calculated.
Good teams have a shared sense of responsibility and the avoidance of personal blame. Psychological safety is important for individuals. It relates to feeling comfortable about asking questions, seeking help, admitting errors, and being able to say I don’t know3. In general, teams perform best when there is a clear purpose such as a cardiorespiratory arrest or other emergencies.
Leaders of clinical teams should have the qualities required to manage the group4. There are three recognized styles, directive which tends to be autocratic, participative which is inclusive, and delegative which equates with laizzez faire. There is no right or wrong approach and many leaders use a combination of qualities depending on the circumstances. However the participative is the most popular type of leader among employees. Listening is an important skill. It doesn’t necessarily come easy to busy people. However it pays great dividends and improves productivity and output. Vision is the ability to step back and focus on the big picture. This is not easy in high volume departments with daily pressing issues. Integrity sets the moral tone for the rest of the staff.
A common situation is that not all the doctors are equally committed to the care of the patient. A patient who is one doctor’s priority, is often not the priority of the others. Not all members of the team are clear about the patient plan. With so many specialists involved in a case there is a role for a check-box on the transmission of collective thinking5. Although doctors see the patient individually, they may not meet as a group to discuss management. In addition, since the advent of paperless systems, the clinical note may be written up later on in one’s office at some distance from the patient and the ward staff. In these situations it is not surprising that the sense of priority can be lost on occasions.
There are common themes running through dysfunctional teams and units. Antagonism between individuals is damaging. Rosenbaum uses the term RDA to describe the behaviours- rude, dismissive and aggressive. The young colleagues are twice as likely as the old to be exposed to RDA. In a neonatal simulation study, the doctors exposed to rudeness performed poorly both diagnostically and procedurally. The era of sub-specialization with its emphasis on profound knowledge adds to the problem. It’s a human trait not being able to imagine why the other individual doesn’t know what we know. These attitudes can lead individuals to be dismissive of each other. Heavy workloads and high levels of responsibility can lead to stress and disharmony among team members.
In the US and to a lesser extent on this side of the Atlantic, the social factors that promote professional camaraderie have disappeared. The time-honoured doctor’s residence with a sitting room has been eroded or removed in many hospitals. It has long been an oasis where doctors met during their meal breaks and discussed their experiences and concerns over current cases. It is good for teamwork and morale. Large medical centres can be impersonal leading to anxiety and social isolation among staff. If institutions want to benefit from good teamwork, they need to put in place and maintain the required infrastructures.
Teamwork is a key component in the delivery of modern healthcare. It works best when the interpersonal relationships and culture of the organization are good.
- Rosenbaum L, Malina D ed. Divided we fall-teamwork part 1. N Eng J Med 2019;380:684-688
- World Health Organisation. Effective teamwork who.int/patientsafety/education/curriculum/who_mc_topic_4.pdf
- Rosenbaum L, Malina D ed. Cursed by knowledge-building a culture of psychological safety. N Engl J Med 2019;380:786-790
- Five important qualities for a medical leader (and one to avoid). beckers hospital review.com/hospital-management-administration. 2015;Sept 15
- Rosenbaum L, Malins D ed. The not-my-problem problem- teamwork part 3. N Engl J Med 2019;380:881-885