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    Teamwork: The Heart of Health Care


    Fresh out of medical school, residents are thrown into a fast-paced world of intense schedules and electronic medical records. At the same time, they must assume multiple roles—learner, teacher, caregiver, leader—all while navigating the complex culture and social structure of health care delivery.

    How smoothly physicians make this transition often depends on the teams they have the fortune or misfortune of being part of, said Brenessa Lindeman, MD, MEHP, chief resident of the Department of General Surgery at Johns Hopkins University School of Medicine and member of the AAMC Board of Directors.

    “All the work we do as resident physicians is carried out within a team-based structure. Learners at all levels—medical students, residents, interns, and fellows—are critical to the overall functioning of the team,” she said. “It’s when people understand their roles, feel like their contributions are valued, and have a sense of belonging that we can deliver patient care in the most optimal way.”

    How important is teamwork in health care? More than 70 percent of medical errors are attributable to dysfunctional team dynamics, according to a 2014 study in Health Care Management Review.

    High-functioning health care teams can enhance medical education and improve outcomes. And they help team members feel invested in their work. Poorly functioning teams often achieve the opposite. Numerous peer-reviewed studies show that group dysfunction leads to burnout, emotional distress, depression, substance abuse, reduced productivity, and other psychosocial issues.

    “Health care is a high-stress environment that requires a lot of people from different perspectives to work together,” said Michael Leiter, PhD, an organizational psychologist and professor at Acadia University in Wolfville, Nova Scotia. “When communication and cooperation unravel among a group of health care providers, patient care suffers.”

    “It’s when people understand their roles, feel like their contributions are valued, and have a sense of belonging that we can deliver patient care in the most optimal way.”

    Brenessa Lindeman, MD, MEHP

    The importance of social dynamics

    Leiter and experts such as Christina Maslach, PhD, an authority on workplace burnout and professor of psychology at the University of California, Berkley, met at Georgetown University Medical Center in October 2015 for the CENTILE International Conference to Promote Resilience, Empathy, and Well-Being in Health Care Professions. A major area of focus at the conference was the importance of social dynamics in medical education and health care delivery.

    Maslach has been investigating the interplay of social relationships in the workplace since 1971 and created the Maslach Burnout Inventory, the most widely used instrument for assessing burnout today.

    “The people you work with are the people who can understand you the best and be the best source of support, but they also have the power to make your life miserable; what people refer to as a socially toxic workplace,” Maslach said. “So the quality of those social relationships and how to make them function as positively as possible is really critical in terms of making things go well or badly.”

    Workplace harmony hinges on community, she explained, and if the community is weak and colleagues are unsupportive—or engage in incivility and bullying—it is difficult to resolve conflict and the team suffers.

    Leiter’s research shows that sarcastic remarks, cruelty in moments of crisis, never apologizing, or simply failing to say hello to a colleague can take an emotional toll. “Small things have a lot of power,” he said. “The nice thing is that they are changeable; however, groups get stuck.”

    Civility, respect, and engagement

    Communication is essential to resolving conflict, said Maslach, but often there is a lack of training to address matters such as, “How do we talk to each other? How do we raise issues? How do we solve conflicts? How do you build trust and support so that if something goes wrong, people don’t hide it or fail to resolve it or get worried that they’ll get in trouble, but instead actually work together to get it solved?”

    At CENTILE, Leiter discussed CREW (Civility, Respect, and Engagement at Work), an intervention strategy that has been used in several health care settings to address interpersonal issues between colleagues.

    After implementing CREW at the Veterans Health Administration, data published in the Journal of Applied Behavioral Science, 2009, showed a “significant improvement” in perceptions of workplace civility that “lend evidence to our claim that CREW interventions cause improvement in civility.” A 2012 study on Canadian health care workers yielded similar results.

    At the Geisel School of Medicine at Dartmouth, Catherine F. Pipas, MD, MPH, assistant dean for medical education and professor of community and family medicine, teaches courses on team improvement. First-year medical students are broken into groups of four and five within their anatomy teams. Each group tracks the team’s collective vision, goals, and role assignments, in addition to how individual team members are progressing in terms of authenticity and resilience.

    “We are all at risk for many, many reasons,” said Pipas. “We are in a health care field where we are constantly giving. We lack control, have a heavy workload, and have increased autonomy—all factors that put one at risk for burnout. So, it’s important that we have trusted relationships so we can depend on others to look at us and say ‘You are not performing’ or ‘We are seeing some change in your patterns; what’s going on and how can we help?’”

    Pipas hopes taking time to examine team dynamics will give students a solid foundation. She also emphasized the importance of self-care through mindfulness, exercise, a balanced diet, adequate sleep, time away from technology, and positivity to ward off burnout and other maladaptive work-related behaviors.

    A sense of belonging

    “Successful teams value individual differences and provide outlets for unique contributions,” said William E. Bynum, MD, attending faculty at Fort Belvoir Community Hospital, in Fort Belvoir, Va.

    In March 2016, Bynum and Lindeman published a commentary in Academic Medicine on learner mistreatment, which sometimes can be triggered by differences such as race, gender, sexual orientation, social views, level of extroversion, mental health challenges, subspecialty, or highest professional degree. Bynum said that successful teams leverage these differences and offer members a sense of belonging. “If there is a feeling you can’t speak up or that you are not psychologically safe bringing what you have to offer to the table, that can really undermine a highly functioning team.”

    Strong teams take time to form, which Bynum said is challenging in a rotational model that switches every four weeks. “Just as you begin to develop cohesion and get to know each other, you are off to a new group with a different set of personalities.” He noted that it is up to attending, chief, and senior residents to set the tone. “There’s a lot of power in positivity, acknowledging that things are going to be hard at times, but as a group you are going to remain as positive as possible and support each other.”

    Maslach agreed, “It’s important to recognize people in a positive way when they do something good. Rather than say, ‘Well, you did your job, big deal, so what,’ if you periodically say, ‘You really handled that patient well, nice job,’ that goes far. It’s huge. It doesn’t cost anything, but you have to be sensitive enough and willing to care about each other.”

    This article originally appeared in print in the May/June 2016 issue of the AAMC Reporter.