Team Intelligence — language is a good place to start
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.
I have been a Phlebotomist at a Northern California Hospital for 17 years. I know every housekeeper, aid, transporter, unit assistant and RN in our hospital by name and we all greet each other as we pass. But no doctor at my hospital for 17 has ever made eye contact with me. It is as though only other doctors exist for them. Consequently, I refuse to take verbal orders from them. Let them go through a nurse if they want me to draw a blood test.
My wife is the Director of the Information System for the 22 Stanford Hospital laboratories. She says that a directive has gone out to doctors there that within 10 feet of approaching anyone in a hallway they are to make eye contact, and they are to greet the person as they pass, no matter who. This seems like a step in the right direction. The problem at Stanford is that all the Doctors think they are such wonks in their field that it is like being in prison–none of them make eye contact with each other because it is a direct challenge and someone will have to establish dominance.