Remember when doctors made house calls? Probably not! Few of us are old enough to remember such a thing. Times have changed and so has the health care profession. There was a time when the doctor knew everything. In a sense, that was true. He or she did know almost everything there was to know about medicine and treating illnesses. No more! The medical field is so vast and complex that no one person can possibly know everything.
Everyone is a specialist. I’ll bet that your primary care physician is some sort of internist, an oncologist or a pediatrician (or a gerontologist). We know much, much more about how to treat diseases than ever before. In fact, there are very few conditions without some kind of accepted treatment, not to say that those treatments always work – there are still plenty of frontiers. More troubling, however, is that the correct treatment is often not prescribed or not administered properly. Why in the world would this be so? Certainly, there are deep, and worrisome political issues that interfere with good health care.
But, the real challenges in health care today are more about how treatments are decided upon and how they are administered. Some of these problems must be ironed out in the public, political arena (Heaven help us all). But, there are also organizational and leadership issues that need to be addressed. These are problems that can be solved.
The model that places a single physician in the position of making all the decisions about how to treat a patient puts many at risk. In complex tasks, having a single, central decision-maker is seldom ideal. As a task becomes increasingly complex, the channels of communication among the “specialists” and the decision-maker become overused, clogged and dysfunctional. Such ideas are not new. Putting people into outer space, playing a professional team sport, flying an airplane, or performing in a musical group requires a more distributed decision-making process. Even an orchestra conductor cannot play all of the instruments nor tell each performer what note to play and when to play it. They must learn to work together. There is a limit to autonomy. When diagnosing and administering treatment for an illness, the risk of “playing a wrong note” goes far beyond a brief unpleasant sound.
“Missing a shot on a fast break” won’t kill a spectator at a basketball game, but mistakes in the operating room can be fatal. The body of knowledge that we now have about medicine and medical practice can be very powerful when used by a competent team. But, to make that work, each team member must be willing to play his or her proper role. And, each team member must have the communication and team skills in addition to their specialized competencies.
In a staggeringly detailed study done by the Institute of Medicine Of The National Academies, called “Core Principles & Values Of Effective Team-Based Health Care,” the authors review much of the research that has been done on teams in health care. They conclude that, “Fundamental to the success of any model for team-based care is the skill and reliability with which team members work together.”
They are not questioning the technical skill of the doctors, nurses, anesthesiologists, or lab technicians. They are saying that to make these teams work, they must have superior communication, listening, feedback-giving, and conflict resolution skills, the skills needed for any team to function at a high level. This is not easy. They go on to say, “At the most basic level, establishing and maintaining high-functioning teams takes work.” – not just the work of providing medical care, but also the work of creating and sustaining an effective team.
“Researchers have identified facilitators of team-based care, or factors that constitute and promote good teams and teamwork. For instance, Grumbach and Bodenheimer found that key facilitators include having measurable outcomes, clinical and administrative systems, division of labor, training of all team members, effective communication, and leadership. IPEC (Inter-professional Education Collaborative) has focused on effective inter-professional work and has defined four domains of core competencies: values/ethics, roles/responsibilities, communication, and teamwork/team-based care (source cited).” All of these factors represent skills that can be learned but are not the focus of our medical education system .
In a very compelling TED Talk, Dr. Atul Gawande compares the current idea of a medical team to a car. Only slightly tongue-in-cheek, he suggests that what happens today is that we take the engine from a Ferrari, the body from a Volvo, the chassis from a BMW, the brakes from a Mercedes, etc. and fasten them all together. The result is a very expensive machine that doesn’t work. That is not a criticism of the excellence of the isolated parts. It is an indictment of the system (or lack of a system). The parts are just not designed to work together. We can have the very best diagnostician, surgeon, anesthesiologist, nurse, and so on but if they don’t communicate with one another, listen to the patient, coordinate, they risk catastrophic errors no matter how skilled they are at their individual specialties.
Dr. Gawande states that “Forty percent of our coronary artery disease patients in our communities receive incomplete or inappropriate care. Sixty percent of our asthma, stroke patients receive incomplete or inappropriate care. Two million people come into hospitals and pick up an infection they didn’t have because someone failed to follow the basic practices of hygiene.” Wow! What a statistic from the country with the most expensive health care system in the world.
Ironically, the best health care results often come from the least expensive groups. The ones with the best results are the ones who operate most like systems – teams – real teams. So what Dr. Gawande’s group did was look at other high-risk occupations that have good success records and try to learn from them. One of their biggest surprises was that all of them did one thing that was not done by surgical teams. Are you ready? They used checklists. That’s right. Checklists! Just like the pilot and crew of a jet liner. So, they tried an experiment in which they implemented checklists in eight hospitals around the world. The result? Complication rates fell by 35% and DEATH rates fell by 47%. FORTY-SEVEN PERCENT! Just by using a checklist.
Closer examination of these results may show that an experimenter effect (Hawthorne effect) may also have been at work in these hospitals. They knew they were part of the study and may have been more careful in other ways. But still, those are very impressive results, and scary, if you are facing a surgical procedure and a stay in the hospital. (Atul Gawande is a surgeon, and public health researcher who also writes for The New Yorker magazine).
To have an effective team you must, of course, include the appropriate mix of skilled people. You need the right equipment and technology. But, the lesson we need to learn is that those things alone, while important, do not, by themselves, constitute an effective team. Working as a team is fundamentally different than working as a collection of individuals. Leadership consultant Khoi Tu examines high performance teams like pit crews (They practice their performances hundreds and hundreds of times.), Pixar (He maintains that is when Steve Jobs admitted that he was wrong and the team was right.), and the Rolling Stones (Each band member played a very different role. The combination is what has allowed them to be the most listened to band in the history of the world.).
His point (among others) is that “…team excellence is a learned habit. Great teams happen as a result of great design and deliberate practice.”
Certainly, there is a growing awareness that excellent teamwork is an important requirement for creating a more effective health care system. “At the Yale University School of Medicine, where the medical curriculum is being redesigned, inter-professional teams already have begun to make rounds together in the nursery. The goal, says Yale Associate Professor of Pediatrics Eve Colson, is medicine’s version of a well-trained flight crew (source cited).”
More and more specialty clinics advertise their “team approach” to treating patients (or “clients” in the more posh clinics). More and more medical schools offer at least some coursework in communication or team development and so on. But, the preponderance of medical care still relies on the old solo hero metaphor. Somehow, being part of a team is seen as demeaning, a step down. After all those years of sacrifice and backbreaking work in medical school, you are “just” one cog in the wheel.
It may seem to some physicians that this is insulting or that it is an abdication of responsibility (Doesn’t the buck stop here?).
So what, exactly, makes a team different from a group or a simple collection of individuals? It is important that teams be formed for the right reasons. Teams are important when there is a high degree of interdependence. That is, the team members need one another to accomplish the task effectively. That seems to be an absolute in the health care industry. In diagnosing and recommending treatment, there are many disciplines that need to weigh in. A gap can lead to terrible consequences. Corporations sometimes form “teams” when an excellent staff would work just as well or better. But the interconnected expertise in medicine means that beyond the simplest tasks (scheduling appointments, administering payrolls, and so forth), teams make a lot of sense.
The following guidelines are a starting point. Most such discussions will present a similar list of important requirements for effective team functioning. Teams need a clear purpose. There should be a well-understood and accepted structure that includes clear roles and responsibilities. All team members should have the appropriate technical and team skills. Teams need substantial resources – money, time, equipment. They need a clear way to measure and evaluate results. (See this article for a more detailed discussion of these requirements.) These principles have been embraced by many forward-thinking corporations. When properly executed, these companies have been extremely successful. It is way past time to apply what we have learned about teams to the delivery of health care.
Effective teamwork would not only improve the quality of our health care, it has the potential of doing so at a far lower cost that today’s “system.” I don’t know about you but I’m dying to get started. In fact, we’re talking about it right now. Join our discussion on Linked In.