During her last year of medical school, Katherine Chretien, MD, FACP, was nervous about starting a rotation in surgery, which was rumored to be especially tough and exhausting. But while the schedule proved grueling—with most days beginning at 4 a.m.—the camaraderie and cohesiveness of her ward team turned it into one of the most enjoyable experiences of medical school.
“It was a very hard rotation but I loved my team and had a great time,” said Dr. Chretien, now chief of the hospitalist section and medicine clerkship director at the VA Medical Center in Washington, D.C., and associate professor of medicine at George Washington University. “It gave me an appreciation for how a good team can really motivate you and make your whole experience different.”
It also provided some insight into what separates a highly functioning ward team from one that never seems to gel.
“We all felt accepted by everyone on the team and everyone pitched in,” said Dr. Chretien. “We had a very strong leader and the residents took time to teach the students and valued our presence. It really felt cohesive.”
Dr. Chretien has since studied team dynamics theory to gain a better understanding of what makes some teams so successful while others struggle. Most teams can succeed, she said, if the members invest some time upfront getting to know one another and establishing common goals and guidelines.
Building a strong foundation
At Beth Israel Deaconess Medical Center in Boston, the foundation for an effective team is laid before the team forms, said Julius Y. Yang, MD, PhD, a hospitalist and associate program director for the internal medicine residency program. The hospital recently changed its system so that teams are geographically located near their patient population and resident team leaders work primarily with one attending physician. That's improved patient care and led to greater familiarity among team members and staff, he said.
“We used to have service where the resident might take care of 15 different patients on eight different floors and might share patients with four different attendings,” said Dr. Yang. “Now, about 80% of a resident's patients are on one floor and about 90% of her patients are shared with one attending.”
Once a team is formed, the first priority is to establish group and individual goals and develop strategies for accomplishing them, said Curtis Wright, MD, ACP Member, assistant professor of medicine at Indiana University's department of medicine and moderator of a workshop on team-building at Internal Medicine 2012.
“Every member of the team has to be motivated to do his or her job and understand why it's important,” he said.
The team leader should establish upfront how team members should communicate with each other, said Dr. Yang. For example, when is it acceptable to call the attending in the middle of the night?
Social icebreakers are key to getting teams off to a strong start and feeling comfortable with each other, added Dr. Wright. “Teams fail when they're all about the business side and fail to work on team dynamics.”
At her hospital, Dr. Chretien starts with an icebreaker to learn about each member's background and role on the team. “It helps to share what people like about their role and what's hard for them,” she said.
Dr. Chretien also introduces games as a fun way for team members to bond. For example, in one game every member is given a card with a diagnosis written on it that only the other team members can see. The goal is for each person to guess the diagnosis on his or her card by listening to the clues provided by the rest of the team.
“It can take time for a team to warm up to each other but on ward teams it is so important to jumpstart that process and make it as quick a transition as possible,” said Dr. Chretien.
Heading off dysfunction
While some conflict is normal, successful teams avoid major problems by establishing clear lines of communication and making sure everyone knows their roles.
“There has to be a clear designation of responsibilities,” said Sanjay V. Desai, MD, FACP, director of the Osler Residency Training Program at Johns Hopkins Hospital in Baltimore. “It has to be clear who is responsible for what part of patient care because any confusion can be very distracting for the team and cause patient care to slip.”
Similarly, everyone should feel empowered within her own area of responsibility, he said. Junior members of the team might feel frustrated if, for example, the nurses don't listen to them or the senior resident cancels a consult that they've ordered or changes a plan of care without telling them.
“If that junior person starts to feel like they're not empowered, they will disengage, which leads to the downfall of the team,” said Dr. Desai.
At academic medical centers, where medical students and residents continuously rotate through, the attending physician must guard against a tendency to dictate, said Dr. Wright. To prevent that from happening, attendings need to define their expectations from the start so that everyone on the team knows the accepted method for completing routine tasks, such as signouts, he said.
“Many of the arguments between physicians on service together are because each is used to doing things their way,” said Dr. Wright, “and there hasn't been a reconciliation moment where they decided, ‘This is what we're going to do because we're a team.’”
It's important to realize that disagreements are a normal part of the learning process, said Dr. Yang, noting that they typically fall into three categories: differences of information, expectations or values. Recognizing the basis for a disagreement is the first step to avoiding major conflict, he said.
For example, before an attending overrides or contradicts a resident's decision on the plan of care, he should try to understand the basis for the treatment decision because the resident may have new or different information. Similarly, team members might be able to reconcile conflicting expectations or values by communicating and making sure each understands the other's point of view, he said.
When it's clear that the resident team leader is having problems, the attending physician sometimes has to step in with advice or to help resolve disputes, said Dr. Chretien. However, the attending's primary role should be as a coach on the sidelines, helping the resident develop as a leader and making it clear to the rest of the team that the resident is in charge on rounds.
“Sometimes I make a deliberate decision not to go on rounds, then touch base with the resident afterward to see how things went,” she said. “When I'm there, the team members tend to want me to make the decisions, but I want the resident to grow into that role.”
Keeping teams on track
Once the ground rules and expectations have been established, it's up to the attending physician and team leader to ensure that the team's goals are being met and everyone fulfills her role.
One way to keep teams on track is by meeting briefly at the beginning of a shift to make sure everyone is aware of new or developing situations, said Dr. Yang. The resident might relay that there are four new admissions, a patient is decompensating and an intern has to be at the clinic that afternoon, for example, so that everyone has an idea of how things will unfold that day.
Besides meeting clinical goals, the senior members of the team have an ongoing responsibility to educate, said Dr. Desai. That means allowing junior members of the team to take on responsibilities in controlled situations.
“It takes effort, time and patience by the leaders,” he said. “It sometimes can seem easier to just do the work yourself, but that can lead to disengagement by junior members who wonder why they're here.”
The team leaders also have to maintain an “uplifting attitude” so the team stays motivated, added Dr. Desai. If a team leader's negativity seems to be affecting team performance, the attending should let them know. “Often they aren't aware that they're leaving that impression and they make an effort to change,” he said.
Enlisting continuous feedback is another way to keep on top of how the team is performing, said Dr. Desai. Johns Hopkins has a 360-degree electronic feedback system, in which each employee completes a self-assessment and receives performance feedback from a variety of people he/she works with, including supervisors, peers and other staff. The system includes a section for anonymous comments.
Academic teams also meet monthly to discuss issues or problems affecting team performance, and attendings meet at least biannually with each team member under their supervision, he added.
Without such feedback, “it is not always obvious that a team is off track until it's too late,” said Dr. Wright. Asking team members to answer a few questions on a feedback form periodically throughout the team experience can alert a team leader to potential problems. Allowing anonymous comments is important, he added, because some people find it difficult to give constructive or negative feedback.
“You need to drill down to what the issue is and tackle that,” said Dr. Wright. “The majority of the time it is that there is a lack of alignment of expectations or goals, or personality conflicts.”
Taking all the recommended steps to build an effective team can seem overwhelming, but it helps avoid more headaches down the road, said Dr. Chretien.
“It feels easier not to put effort into it, not to take the time to do the icebreakers, and establish goals and expectations,” said Dr. Chretien. “But you can be more efficient in the end if you do it and you can avoid some of the problems that keep a team from working well together.”