Good afternoon.
I am so excited to talk to you about something I am very passionate about.
And maybe I will connect with everyone in this room and then you will leave being passionate
about it as well.
Teams and healthcare- It's a topic I think about on a daily basis.
And I first want to start because I think I have an assumption all of you in this room.
I think all of you have been in your lifetime on a winning team and on a losing team.
You can probably think about what that feels like.
I have two small children and already they are on many informal and formal winning teams
and losing teams.
And it is an interesting concept: we are sitting in a basketball stadium here and that is okay
when you think about adults on maybe professional teams, but when you walk into a hospital or
you walk into go see your primary care physician, you probably don't think 'does my nurse feel
like she's on a winning team?'; does my surgeon feel like they are on a winning team?'; 'do
I feel like I am on a winning team or a losing team?'
But really when you start thinking about the basic unit of teamwork in a healthcare setting,
it is a really important foundational component that we need to train our future providers
to be a part of and to contribute to.
I started thinking about teams early in my career; I started at the University of Southern
California.
My dissertation work in educational psychology was on expertise.
Now, I like smart people and I picked surgeons.
They are very smart people; they are task oriented; and they definitely develop a real
expertise in their field.
And when you start to think about how can you bridge the gap between a novice trainee
to an expert surgeon, you have to deconstruct that expertise.
I used to think it was the psychomotor skills- how they throw a stitch, how they tie a knot.
But really it was when they zig and zag and how they make the decisions they do that we
needed to deconstruct.
And in fact when you put an expert surgeon with a novice surgeon they have a hard time
articulating why they did it because it has become automated for them.
They have chunked those steps together.
So how can we break this down as an educator?
With something I spent a lot of time in my early career doing in the simulation center.
We would have task trainers and procedural trainers and we would try to bridge that gap.
Now surgeons cannot spend all of their time in a simulation Lab, they have to be in the
O.R., this is something they like to be in.
So we shared our simulation lab with some other people.
One of the groups, one of the educational groups, was the US Navy.
Now the US Navy picked the Los Angeles County USC Public Health System as their trauma team
training center.
They would bring their Navy Health care teams to do intensive 30-day training before they
were deployed to Afghanistan or Iraq.
And they would use our simulation center.
On the Navy days they would come in and they had stuff.
[3:02] And they had people.
And they were efficient.
And they knew exactly what they were doing.
The tone of their discourse was flat.
They would do their scenarios and debrief and they knew exactly what they did right
and exactly what they did wrong.
I was like "Wow, this is kind of impressive."
It kind of scared me a little bit.
Imagine if we did this with our surgeons, I wonder how they would interplay with that.
And it really became a need that I started to identify that I do not think we do in maybe
our civilian training.
What does this mechanical teamwork component look like?
And it was absent from our education of our trainees at that time.
Then I was fortunate enough and my career took me to be on faculty at Harvard Medical
School at Brigham and Women's Hospital.
I arrived to Boston a little nervous and excited and they were doing team training.
But their team training was around patient safety and error detection.
It was about working at the bottom and bringing it up.
We are going to create these efficient teams and effective teams to prevent error, and
safety.
I was like "Oh, okay, I get that."
And I had the chance to work with someone who I really like to read and I recommend
to everyone.
Atul Gawande, who is a surgeon writer who has written in the New Yorker and has written
some wonderful books.
He talked about the old training model was we created cowboys.
They were on their horse in the Wild West and these physicians were going to go save
the wild west.
But what we needed to do was train pit crews.
Patient comes in, we the swarm the patient, patient goes out.
Next patient comes in, we swarm the patient, the patient goes out.
We have a tire specialist, we have a gas specialist, we have a window specialist.
It's like well okay, that is kind of interesting, that is the nurse, the anesthesiologist, the
surgeon.
That was a different framework.
I thought that was interesting and I had a chance to receive a grant to do some O.R.
team training.
We were going to take attending level surgeons, anesthesiologists, and nurses and have them
come and do some O.R.
team training to improve team safety.
This grant said they wanted us to teach three objectives.
Now as an educator, I am all about my objectives.
And these objectives were: closed loop communication, assertiveness, and using a safety checklist.
Dream job, right?
I get to work with fancy pants Harvard surgeons and anesthesiologists; I only have to teach
these things, three things; we are getting paid for it.
This is great.
So we had fun.
We created scenarios and we had a whole training program.
They were going to come for six months.
And when you do simulation training, you want to make sure your fidelity is right, that
you give them enough tools that are like what they use in their real environment to be successful,
and you want to give them a clinically challenging case, but you also want to make some twists
and turns because it creates conflict or a need to discuss things.
Our first scenario was we wanted to take these O.R.
teams in attending, they are done with their training, and they are getting paid and are
on staff with the Brigham.
We wanted to take the out of the O.R. and our first scenario was in the recovery room.
[6:02] We know when we take teams out of their micro system, they struggle a little bit and
we will see how they can handle it.
So the first case, we'll call him Mr. Monson.
The team walks in and he is in the recovery room, which is the room right after surgery.
It is a simulated patient, a manikin.
And the teams acts pretty much how the surgeons go in.
Where's the chart?
I need the chart!
We're going to solve the problem.
They have the cognition; they are going to solve this puzzle piece.
The nurses go into the room.
And if any of you are healthcare providers, you know, a nurse is not a nurse is not a
nurse.
They fine tune and hone their skills in the different environments.
So when you take OR nurses and you put them in the recovery room, there is different equipment,
there are different drugs they would push, there is different everything.
So it gets them a little unsettled.
They are looking at the inventory and the equipment, the feeds of information they have.
And then we have the anesthesiologists who we thought would be the leaders in the room.
There were two anesthesiologists.
One was senior, twenty years of experience.
And one was three years out of training.
He had completed all his training and been working for three years.
They walk into the room and the senior anesthesiologist goes into the code cards.
And she is looking for stuff and the patient is back here.
She has her back to the patient; she's looking.
We were like, this is interesting.
The person we thought was going to be the leader did not do it initially.
The junior anesthesiologist attending goes to the head of the bed starts bagging the
patient and looking around and taking it all in.
They struggle; they are having parallel conversations amongst the dyads for a while, ninety seconds,
maybe two minutes in the sim world.
This isn't good.
When are they going to engage?
They have to come together.
And the junior anesthesiologist says I am worried about a PE because...
The whole room turned, focused, was facing the patient, and information started to flow.
They had their framework.
They knew what they were going to do.
But that junior anesthesiologist remained the leader of the team and continued to give
orders, process, give direction, and became a team member.
Success.
We walked down the hall.
We were going to debrief this simulation because that is where we think the real learning is.
Let's reflect on our shared experience and talk about it.
And whenever you work with smart, accomplished people and you put them in a room after they
have done a performance based assessment, they sit around the table and you say, "how
did that go?
How did it feel?"
And they go, "Horrible.
That was horrible.
You know we would never have that equipment.
Things would be different.
It is never like that.
I always do it perfect."
Well that is good.
They are getting off their emotion.
And then they circle around and start saying, "yeah, you know, we figured it out; we solved
the problem.
We stabilized the patient.
That was very complicated.
It was good."
They are coming together as a group.
They are coming together as a team.
They are starting to develop and identity.
Then I say, "Was there a leader to the team?"
[8:56] They said, one of the surgeons sits back, and goes, "that's an interesting word,
leader.
I mean, aren't we all leaders here at Harvard?
I mean, I am never not a leader.
What do you mean not a leader?
When would I be a leader?
What do you mean by that question?"
Well, I will reflect it back to the group.
Was there a leader in the group?
Some people were kind of quiet and did not say anything.
I turned to the junior anesthesiologist and said, "Well what I observed was that you were
the leader.
And that you were the leader because you gave the framework for the team to come together.
And she goes, "Oh, no no no.
My colleague has the expertise in the room and it was really a group effort."
That is when I knew that this was more than a pit crew.
There are powers in play in healthcare teams.
They are about hierarchy, culture, and power.
It is three-dimensional.
It is not just training people how to take the wheels off of a car and do it efficiently
and effectively every time.
There is another element to this in our complex system.
And then I swear to goodness, I came to Rochester and it all came together for me.
I met a wonderful woman named Maddie Schmitt.
Maddie Schmitt is an internationally renowned theorist and writer about inter-professional
education.
She comes from the nursing world.
And two years ago she wrote, was the lead author, on a very important document that
was endorsed by the top organizations in medicine, nursing, pharmacy, dentistry, and social work.
She defined the core competencies for inter-professional education.
She said, "We need to learn with, from, and about each other so we can provide our great
care.
It is not enough that in our different disciplines we know how to treat, manage, and diagnose
from our specialty.
But we also need to be experts in how to communicate, collaborate, and coordinate.
And we have to deliberately teach it.
We cannot just think people come to us with this innate knowledge of how to do those things
and our curriculum needs to encompass that."
My future vision of dream teams is just that it is a round table of specialists and providers
who come together and share their expertise.
But their expertise is not just in how they practice medicine but is in how they communicate,
coordinate, and collaborate with each other.
And a big component of that is you, the patient.
The patient and your families are not the subject of our teams, but you are on the team.
You get a jersey.
You are on that and we need to train providers who can help you have a voice and feel empowered
and integrated and can help direct the team.
Those are the things we are thinking about and I really appreciate the opportunity to
come share that with you.
Thank you.