Building Team Intelligence (TI) — the capacity of people to learn, think,reflect, and act together — has been a major focus of my research for several years now. In fact, I am writing a book with an airline pilot and medical educator on the aviation safety movement and how it changed aviation culture. The book – Come Fly With Me — considers what those working on quality and safety in health care can learn from the aviation safety movement.
As my colleagues and I have been working on our book, we have been looking at examples of similar transformations in health care settings. We now know that safety –whether in an airplane or an operating room — depends not simply on technical proficiency but on team work and the development of team intelligence. Last week, I saw an impressive example of Team Intelligence in action at the University of Toronto, in Ontario where I had the privilege of learning about the work being done by the University of Toronto’s (U of T) Faculty of Medicine’s Wilson Centre for Research in Education and its Centre for Interprofessional Education . The work these two centres are doing both on their own and in collaboration is fascinating.
Although many Canadian health care researchers had long been interested in promoting inter-professional education and practice, their efforts got a huge boost after the Romanow Report on Building on Values: The Future of Health Care in Canada that was released in 2002 . The Romanow Commission, led by Roy J. Romanow, considered the future health of Canada’s Medicare System. One of its key recommendations was creation of initiatives that would promote Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP). The Canadian federal government took on this challenge by setting aside millions of dollars to fund Interprofessional Education and Practice in Canadian schools of medicine, nursing, pharmacy, dentistry and other health professions. In Ontario, the government added to that federal effort by setting aside money to fund both inter-professional education and practice .
The University of Toronto, with its Wilson Centre and Centre for Interprofessional Education, is at the heart of these efforts. The director of Wilson Centre is Brian Hodges, a psychiatrist who wrote the clinical commentary for Chloe Atkins amazing book My Imaginary Illness: A Journey into Uncertainty and Prejudice in Medical Diagnosis published by our series The Culture and Politics of Health Care Work at Cornell University Press.
Hodges and his colleagues at the Wilson Centre are producing important scholarship on inter-professional education and practice. Maria Tassone, is the director of the Centre for Interprofessional Education where she and her colleagues are putting theory into practice in more ways than one.
The programs that have begun at the U of T offer many lessons to offer those interested in teamwork in health care in the US and elsewhere. All health care faculties at the U of T are now working together to introduce all 1400 of their students to inter-professional education. Each and every student has some contact with students in other schools as well as with interdisciplinary and collaboration in the practice setting. Although the Centre for IPE is working to build capacity so that students can gain inter-professional experience in a serious and sustained way, initial efforts are promising. For example, some students are brought into the hospital and other health care settings in structured placements in which they interact with students from different health care faculties as well as with professionals from different disciplines. Thus, a student in speech language pathology (SLP) told me how she and an occupational therapist collaborated to help a wheel chair bound patient. As the SLP student watched the OT student adjust the patient’s wheel chair, she realized that the patient’s problems with swallowing were eased. She confessed that, without this hands on interdisciplinary experience, she would never have thought of calling on an OT to help with a swallowing problem.
While students engage in activities outside of the practice setting, one of the most interesting aspects of this program is how they interact within it. Bringing students together in an interdisciplinary group within the practice setting has a ripple effect on the setting itself. That’s because Tassone and her colleagues are trying to make sure that what students see in practice doesn’t contradict — or even erase — the lessons they learn in theory.
We all know how the hidden — or not so hidden — curriculum in nursing and medicine and other health disciplines can completely eradicate more positive lessons students may have gotten in the classroom. Thus an RN student will be told that they have a great deal of skill and knowledge only to be confronted by a physician who treats them like little more than a handmaiden. Or a medical student will be told that teamwork is now the mantra in health care only to watch an attending physician bad mouth pharmacists or disregard the contributions of the dietician in the treatment of diabetic patients. To make sure this happens as little as possible, The Centre for Interprofessional Education also targets the faculty whom students will meet in the practice setting. Indeed, the Centre for IPE hosts a five day session each June to help faculty learn how to teach in a way that enhances rather than defeats teamwork and collaborative practice.
All of this attention to team intelligence in action (TIA) helps to produce greater awareness and attention to teamwork in the practice setting. As students are educated so are working professionals as well as those who work in other health care occupations. Indeed, a number of the teaching hospitals in the U of T system have launched serious collaborative practice efforts into which students can be integrated after they have graduated.
Although I plan to post on this more, I want to conclude with something Maria Zhang, a student at the Leslie Dan Faculty of Pharmacy wrote to me about her experiences in her inter-professional placement. It illustrates the promise of genuine efforts to move students out of their silos (or really, fortresses) and to teach them greater regard for those with whom they will be working in as they enter practice. I would like to thank Maria for sending this.
From November 2010 to December 2010, I completed an inter-professional education placement at Toronto Rehab, a teaching hospital that provides complex care and specializes in adult rehabilitation. I worked with a group of students from other health care professions including occupational therapy, physical therapy and nursing. Our group was co-facilitated by two very knowledgeable and helpful Toronto Rehab staff members, both with nursing backgrounds.
We met on a weekly basis to work through case studies of patients in the Geriatric Psychiatry ward and through these case studies, we delved deeper in understanding each other’s roles and our own. For example, for the communication barriers case study, a Speech Language Pathologist (SLP) working on the floor, joined us for our discussion and offered her insight. This was extremely valuable as we did not have an SLP student within our group. On a weekly basis, I also met with my pharmacist preceptor who is a clinical pharmacist at Toronto Rehab and she briefed me on all of the patients and provided profound clinical knowledge and insight on the specialized role pharmacists take while working in the Geriatric Psychiatry ward along with her personal experience with practicing pharmaceutical care as part of a team of healthcare professionals.
Overall, this was an invaluable experience that has made me excited to learn and do more in my clinical practice. Just collaborating with students and learning about what their entry to practice process is like, the future of their profession and the roles they play in different settings, was eye-opening.
The importance of collaborative care cannot be underscored enough. One example that demonstrates this for me would be when our discussion was around a patient on the floor who was a concentration camp survivor. He had been admitted for reasons similar to most patients on the floor; sexual disinhibition and aggressive behaviour. Our inter-professional team gave insight on how the team approach has helped our patient.
The social worker kept in contact with the family, gave them regular updates on the patient’s progress and asked for consent for procedures, medications and more. If the patient is unable to provide us with their opinions, then we enlist that from the family as they are critical to any team approach as well. The occupational therapist and assistant worked with him and found out that he enjoyed music and singing and that this calmed him. The nurse found that he was agitated in the morning when medications were administered. Based on his history, we discussed that his may be related to him reliving his experiences at the concentration camp where he may have been forced to awaken suddenly and had his blankets ripped from him. As a team, we brainstormed that perhaps warm towels can be used to ease the blanket removal process or whether medication regimens could be altered so that he could take the medications at a time later in the day. These processes would have to be discussed between the nurse, pharmacist and doctor working with the patient.
This experience has been enlightening and enriching. It has helped me understand much more about my own profession’s role in healthcare provision along with a few other professions. It has helped me learn more about the importance of collaborative care and how we all play integral parts in the overall picture of maintaining and/or improving a patient’s health and quality of life. Most of all, it has fuelled my passion to learn and participate more in inter-professional experiences.
I have spent a lot of time watching doctors and nurses and other health care workers and professionals function in hospitals and other health care settings. The very first thing that impressed — or rather depressed — me when I first went into the hospital over 20 years ago was how little real communication there was between doctors, between doctors and nurses and between doctors, nurses and other professional or non-professional staff. Very few had what I have come to think of as Team Intelligence. What I noticed then and what I still notice when I go into hospitals is that there’s an awful lot of action but very little interaction. A lot of activity but not much interactivity. And how could there be when people function not just in silos but in heavily armed fortresses where they spend much of their time defending themselves against what they conceptualize as invading armies. (If health care workers and professionals only occupied silos, we’d be in better shape and it would be easier to re-form the system. Silos after all aren’t fortified.)
The inter and intra group relationships are really disturbing. The nurses who I write about are very focused on how poorly doctors treat them, but they rarely consider how they treat lower level staff — the cleaners, and LPNs and aides and so many others who make the hospital or other facility world go around. When my mother was dying in a nursing home, in 2002, I spent nine days at her bedside in a vigil after she refused to eat or drink. I watched the RNs treat the LPNs brusquely and rudely and the LPNs return the favor when they talked to aides. These aides are referred to as “nurse extenders,” as if they have no occupational identity of their own. And this term is used by people who dislike being called “physician-extenders.”
Nurses have all sorts of other ways to put each other down. Four year university degree nurses view themselves as “professional nurses,” and seem to dismiss the skill and competence of nurses who have gone to two year schools because they are just “technical nurses.” Enter the advanced practice nurse, who views her or himself as way above the two year or four year RN because he or she can prescribe and diagnose and is thus advanced. Consider the language here. You have different skills than a direct care RN — but you are an advanced practice nurse. So what does that make a veteran, expert, registered nurse who has spent 30 years honing her craft at the bedside? Is she inferior, retarded, delayed — all words that the thesaurus tells us are the opposite of advanced. I know now NPs, who refuse to even use the word nurse, or who don’t want to be viewed as “just a nurse.” How can these NPs, work effectively with RNs (which by the way an NP must become if he or she is to become an NP or APRN) if they have so little respect for the job and the person in it?
If nurses don’t respect one another, how can they expect doctors to respect them? If nurses put down one another, how can they expect doctors not to put them down?
And then let’s look at how docs treat each other. Over the years I have heard doctors — who nurses think to be the ultimate team players who stick together through thick and thin — belittle one another shamelessly. A surgeon I know commented dismissively that oncologists are just “hand-holders,” and don’t “do anything” for their patients. An internist insisted that my friend the gyncological surgeon wasn’t really a surgeon because she only did a limited number of operations. Another friend told me she’d heard an internist comment dismissively about an orthopedic surgeon who’d just had brain surgery — “oh, he’s just an orthopod,” like he didn’t really need a brain.
Junior doctors are afraid of attendings, afraid to point out problems in patient safety because they will be reamed out because they don’t know something that they couldn’t possibly know because they are novice/learners. They are afraid to admit to mistakes when we know that the way we learn is by making and learning from mistakes. In my work with doctors and nurses, I have seen a lot of tension and conflict result from the fact that the physician-in-training is trying desperately to get a nurse to help him or her cover up a mistake just before rounds (and just at nursing shift change) because he’s afraid to get reamed out by the attending. Rather than acknowledging the need for help (which he or she is not supposed to do because doctors give orders to, not ask for help from –nurses) the doc becomes demanding just when he or she should explain the problem and ask for assistance. Some nurses who think they know all about physicians misinterpret the physician-in-training’s actions and chalk it all up to those damn doctors who don’t appreciate nurses. While some doctors don’t, in this kind of case, the conflict between the novice doctor and nurse is generated by intra-group dynamics.
We talk a lot about teams in health care. And God knows patients like myself need them. But we’ll never create genuine teams unless people in health care do a lot of mental redecorating. How you think about the person who works next to you, the language you use to describe their role versus your’s is a great place to start.
This fall, our series at Cornell University Press on the Culture and Politics of Health Care Work published a remarkable new book. It’s entitled My Imaginary Illness: A Journey Into Uncertainty and Prejudice in Medical Diagnosis and its written by political philosopher and professor at the University of Calgary in Canada Chloe G. K. Atkins. The book is part of a collection we are doing at the Press which is called How Patients Think. The series was inspired by Jerome Groopman’s book, How Doctors Think. Each book in the series begins with a short contextual commentary written by a medical professional – in this case by Bonnie Blair O’Connor, a medical educator and ethnographer. The book then moves to the patient narrative and concludes with a clinical commentary written by a physician or nurse. The commentary is intended to ask what we can learn from the patient’s story and consider how clinicians can change their practice and thus improve the patient experience and patient care. In this case, Brian Hodges, M.D a Professor of Psychiatry at the University of Toronto and director of U of T’s the Wilson Centre for Research in Education has written a brilliant clinical reflection about Atkins’ experience.
To say that the the story Atkins tells is important is an understatement. It is one that is too often repeated in a medical culture fixated on rigid categories of diagnosis in which doctors – and nurses – are infected with a very particular disease (or as Atkins would put it, prejudice). The physician is expected – and expects him or herself – to come up with an iron-clad “accurate” diagnosis of the patient’s problem, treat the problem, and fix it – hopefully forever. If the physician cannot come up with a diagnosis – and quickly – the search for blame begins. Rather than blame themselves, the state of science, or simply the human condition; rather than realizing that, in fact, blame is not the appropriate category to apply to the experience, physicians quickly blame the patient. If the physician can’t find a clear organic cause for the illness, then it must be in the patient’s head. He – or in this case, she – is nuts, has conversion hysteria – maybe the patient or someone in the patient’s family is even deliberately making themselves sick to get attention, as in Munchausen’s Syndrome or Munchausen’s by proxy. Rather than compassion and empathy, terms like “secondary gain,” “wasting time and resources,” “faking it,” are bandied about.
In this case, when she was only 20, Chloe Atkins developed mysterious neurological symptoms. She had serious motor problems, at times couldn’t walk, at times could not even move. Maybe she had a stroke. Maybe she had this, or that. Maybe, maybe, maybe… But no matter how many tests or interventions were delivered, Atkins would recover, slightly, then relapse, then get better, then sicker. No one could figure it out. So, doctors decided it was all in her head. The diagnosis became conversion hysteria and that’s what went into the chart. And the chart was no longer a constructive medical chronicle used to convey relevant clinical information, but a rather what O’Connor correctly dubs “a rap sheet” that contained the allegation and evidence and the patient was, in effect, rendered a medical criminal. Even when she was lying in bed, unable to move a muscle and on a ventilator, doctors and nurses turned against Atkins. (For those nurses who read this, read carefully, because yes indeed, nurses appear little better in this account than MD.s) Even if she were mentally ill – which she was not – one would imagine that caregivers would deliver compassionate care (after all a mental illness is every bit as much of an illness as a physical one). One would be wrong. People who were immediately sympathetic, suddenly became detached and judgmental when they read the “rap sheet’ and discovered that it was “all in her head.” What made things even worse for Atkins was the fact that she wasn’t the picture perfect patient (is there such a thing?) with a loving family at the bedside waiting to fulfill her every need. She was estranged from her parents, which simply confirmed the “rap sheet”" conclusion that she was a head case and deserved no sympathy whatsoever . As Hodges so eloquently puts it, instead of exhibiting curiosity about the patient, they became angry — and,as time went on and she refused to get well, even angrier — at the patient.
And so it went for 20 agonizing years. With the exception of the odd doctor or nurse, the majority of so-called caregivers who Atkins encountered, were either blaming, or downright hostile. What is even more tragic, from my point of view, is that RNs exhibited as much callousness as physicians. (And, least you be tempted, if you’re a nurse, to dismiss this as atypical, recall all the books and chronicles of patient experiences like Ann Fadiman’s brilliant If The Spirit Catches You and You Fall Down, or renderings of Helen Haskell’s experience of the death of her son Lewis Blackman. Invariably nurses are as susceptible to the disease of anger at the patient as are MDs.)
Finally Atkins found a physician who was willing to believe the patient and decided that uncommon form of Myasthnia Gravis was the working diagnosis. Atkins was treated with MG medication and is a great deal better. But her diagnosis is still contested and she fears that, if she falls into the hands of the wrong doctor, she will once again be stigmatized as making it all up. For fortunately, her current physician has a concept of what I call a “good enough diagnosis,” – one that works, one that helps the patient but one that may not conform to the strict medical rendering of a disease as it has been defined by the medical gods who dictate the precise parameters of a condition and who seem to think they own not only the diagnosis but the patient’s experience.
In his conclusion, Brian Hodges asks doctors and nurses to think about why they so often react to complex patients with anger rather than curiosity and to ask themselves, “am I part of the solution or part of the problem?’
Since publishing this book a few short months ago, I have encountered more and more patients who are having or have had this experience. A friend in California is suffering from unexplained and debilitating dizziness. Doctors examine, probe, investigate. They can find “nothing” physical, so as my friend’s life becomes more and more constricted, they declare that it must be all in her head — which, by the way, it probably is, but not they way they mean. Another friend’s 24-year-old daughter has mysterious stomach problems — can eat barely a thing, is constantly constipated. More probing, more head scratching, until finally, violating every patient privacy rule on the book, the physician calls the mother (without the daughter’s permission) and asks her about her daughter’s mental status. The mother is shocked. Finally, he effectively fires the patient by telling her there is nothing he can do for her –maybe she should go to a psychiatrist. Finally, another friend, an internist who teaches residents at a teaching hospital here in Boston confided that when he and other physicians and physicians-in-training see a chart the size of the one Atkins had produced, they inwardly groan. Patients with charts like telephone books are referred to as “frequent flyers,” and the object of the exericse is to try to get rid of the patient like a hot-potato, as quickly as possible. In our increasingly Midas muffler shop like, industrial medical system, the idea is throughput, getting the patient in and out not exploring and sticking with it over the long-term.
When I read Chloe Atkins book in manuscript, I was convinced it had to be published. I have never had a similar experience — at least not one so serious and persistent. But I have, like the people above, encountered doctors who couldn’t figure it all out and who decided I was to blame. I sympathize with their dilemma, as does Brian Hodges in his clinical reflection. I can only imagine how hard it must be to see a parade of patients, day after day, year after year, all suffering from something, all wanting to know why, all pleading to be fixed. With our obsessive fixation and promotion of medical miracles and those who perform them, our society and our medical system often make it impossible for doctors to arrive at a “good enough diagnosis,” and thus we inadvertently encourage the kind of callousness and arrogance Atkins and so many other patients encounter. It’s the opposite side of the miraculous coin. And it needs to be changed.
I hope everyone who reads this will read this book and more important, that they will reflect on Hodges’ question and suggestions. Medical professionals need to be able to express and explore their anger and frustration. It shouldn’t be turned inward, and it certainly shouldn’t be turned toward the patient. It should lead instead to the curiousity and compassion for the human condition that Hodges prescribes. Ultimately, that is the only Rx that will actually work.
Most of us don’t think of our families in terms of teamwork or team leadership and membership. I know I certainly don’t. I think a lot about teams when it comes to colleagues with whom I work. I also think a lot about teams in my professional research. In fact, I am writing a new book entitled Come Fly With Me, with two colleagues — a pilot and medical educator — about team work training in aviation and its lessons for patient safety. In aviation, with the development of Crew Resource Management (CRM) and Threat and Error Management (TEM) the emphasis is on sharing critical information with all of those on the crew — no matter what their position in the hierarchy — in order to prevent terrible accidents. When I work with colleagues or observe the status quo in health care, I am constantly thinking about information sharing — and its lack — and patient safety. I was struck the other day, however, about the application of the team work model to everyday life — life outside of the professional arena, life inside the personal one.
Let me tell you why?
I was in New York, sharing a small hotel room with my eldest daughter, 26, and my husband. We had come from Boston where we live and were spending a few days between Christmas and New Year in the Big Apple. My daughter was flying back to her home in El Salvador and was repacking her bags to leave on an early morning flight the next day. While my husband was out doing errands, my daughter was sorting through her luggage and discovered that the glass on a framed painting she’d brought with her had broken. It had, in fact, snapped into two large pieces — one with a particularly jagged and dangerous point. She lifted out the piece with the rather frightening point, handed it to me and asked me to put it in the garbage. I did. Point up. I then put the less lethal portion of glass into another waste basket. We both knew the glass was in the garbage and we clearly assumed we were the only people with the need to know. It’s not that we decided not to tell my husband and her father. It’s that we didn’t think of it at all. Not for a second.
She finished packing, my husband Steve returned to the room and we all went out to dinner and to a play. We got back and went to sleep, setting the alarm for 3:30AM, as she was going to be picked up to go to the airport at 3:45. I woke up dutifully and kissed her goodbye and my husband took her and her luggage down to the waiting taxi. I blissfully went back to sleep thinking all was well. Which it was. Almost.
When I woke up at about 9, my husband was awake and I asked if my daughter had gotten off okay. She had. She was fine. He wasn’t. What had happened, I inquired?
Turns out, that bleary eyed at 3:30AM, he’d swept something into the garbage and discovered — that is his hand discovered in the most painful way — the jagged piece of glass I’d left sticking right out of the garbage. He’d cut his thumb badly. Not wanting to alarm my daughter, he’d gone into the bathroom to stem the profuse bleeding with some kleenex and then stuffed his hand into a glove so she wouldn’t see it. The person on the desk in the wee morning hours gave him some bandages and he –somewhat uncomfortably — went back to sleep.
You can imagine what I thought when I heard this story and the names I called myself. Not only was my husband’s thumb badly cut,but I was horrified to think that he could have had an even more serious injury if his hand had hit the glass a little lower and he cut the vein in his wrist.
What occurred to me after my initial reaction of guilt and horror, was that I had failed to apply the rules of teamwork, safety, and information sharing that I study to my own family. When my daughter handed me that piece of glass and I put it away, I didn’t think, “you have to warn Steve about this.” Alex and I knew about it and that was, from my own blinkered point of view, all that needed to happen. Not only did I not share crucial information, I didn’t manage a potential threat effectively at all. I deposited that large piece of glass in the garbage point up, when what I should have done is taken it to housekeeping and asked them to safely get rid of it. The threat I had to manage wasn’t only a threat to us, but to any housekeeper who would have to clean up after us. For safety purposes, she was also a member of the team.
Of course, the first thing I did after looking at my poor husband’s thumb was take the two pieces of glass to the housekeeper with firm warnings to be really careful and many apologies for asking her to throw out the broken glass.
But this is how accidents happen. It’s because we aren’t considering who needs to know and because we aren’t thinking about preventing threats to people who are out of sight and thus out of mind. Team theory can help with this. It can be applied to lots of different areas of life. In fact, I increasingly think of the lessons of Crew Resource Managment as Life Resource Management (LRM) . Sometimes, the rules of CRM applied to Life Resource Management is just what you need to get you out of all those pesky patterns you establish over years in a marital or family relationship. Thinking CRM or TEM would certainly have protected my husband’s thumb.