A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
As a physician anesthesiologist in a community hospital setting for more than 25 years, the quest for mastery keeps my practice from getting stale or boring. I relish the technological innovations in the past decade: the video laryngoscopes and ultrasound-guided nerve blocks that allow my skills and competencies to be ever-challenged. There is a magnetic draw to new procedural techniques, such as trancatheter aortic valve replacements (TAVR), which allow us to provide previously untenable options to patients.
Just like the Institute of Medicine articulates in its six domains of quality, these seductive and intriguing technological advances give us tools to make care safer, more effective, patient-centered, timely, efficient and equitable.
I get it. We love new technology.
Yet I’ve come to believe that the newest challenging competency and skill for us as physicians — and health care in general — may not require fiberoptics, lasers, nanotechnology or metabolomes.
It’s teaming. Not teamwork, but teaming. I came across this intriguing proposition reading Amy Edmondson’s book on teaming. If you are short on time, there is even a “cliff notes” version titled Teaming to Innovate.
Teaming, as I understand it, is not simply the verb for a team. It is not simply people joining together to form a team. It is not attending a mandatory workshop on team training. It is not wearing a jersey declaring my team.
Teaming is a mindset and a skill set. It does understand that people in clinical teams join and leave often and always; the knowledge we need to sort through is often unknown and unexpected. Seconds count. There is no luxury for drills and practice sessions. Our patients are lying, vulnerable on hallway gurneys; we must integrate crucial information to make immediate decisions — deliver immediate care.
Although the airline industry is often used as an analogy for team training and crew resource management, airplanes don’t constantly make mid-flight crew changes; individual pilots don’t fly every type of aircraft. Whereas the airline industry has expected and unexpected procedures codified/blueprinted into standard operating procedure and standard contingency procedure binders, the ability to blueprint is rarer in clinical care.
Dr. Edmondson tells me that teaming is teamwork on the fly. She shares the case of the Chilean mine rescue in 2010 where 33 trapped miners, Peru and the world were thrown into a situation without a blueprint.
My takeaways and how it applies to me?
1. Teaming is a mindset for commitment, not compliance. The current glamour around checklists has taken on an audit and compliance overcoat. Leadership, management and the trickle-down team effect that over-focuses on compliance actually creates a falsesense of security that can adversely affect patient safety. Peter Pronovost and Charles Bosk have opined that the emphasis on checklists is a “Hitchcockian ‘McGuffan,’ a distraction from the plot that diverts attention from how safer care is really achieved.”
Yes, surgical checklists have been shown to be effective in a recent meta-analysis, but they must be implemented with a shared commitment of teaming in mind.
2. Teaming is a mindset for collective, not consensus, decision-making. Beware of consensus. Too often, teams look for consensus. Consensus can result in dumbing down a decision. James Surowiecki in Wisdom of the Crowds advises us that true collective decision-making requires independent assessments coming together to reach the wisest decision. When I bring together a group of people, propose a solution and then ask, “Any questions?” “Anyone disagree?” I’ve actually closed down discussion — I’m seeking consensus. Recently, to gain a more collective perspective for patient care, I have changed even my conversations with patients from “Do you have any questions?’ to “What questions do you have?”
3. Teaming is a mindset that embraces autonomy. On the surface, this might fly in the face of the oft-heard view that physician autonomy vexes health reform. I (and I believe the concept of teaming) am of the completely opposite view. If we believe that collective decision-making is vital, then we must embrace independent thought. Psychology research tells us that autonomy (choice) is critical for intrinsic motivation. Wipe that out, and we have wiped out the heart and soul of clinicians.
But, when the underbelly of independent thought and choice is arrogance, we have a problem. Teaming does not tolerate arrogance.
So, I will pick and choose my checklists. I will cast a wide net for partners, including my patients and those outside the sanctity of my operating room suite. I will value and nurture autonomy. This means that the most challenging part about the learning curve for teaming is achieving a common mindset around these concepts — finding others who will grow team mastery skills with me. Teaming, unlike learning to use an ultrasound machine or a videoscope, is not a single-handed enterprise.
Don’t get me wrong. I still love technology and the challenge to learn the competencies of yet another device. But the immediate challenge and competency I have set my sights on to further my mastery in medicine is to gain mastery in teaming.
Della M. Lin is an anesthesiologist.
