Forum Focus – Communication, collegiality, and care (part two of a two-part series)

By Bill O’Neill, Director of Outreach and Communications for the Center for Personalized Education for Physicians

Pitfalls and Perils on Medical Teams

In recent years, changes to the structure of medical teams, intended to improve communication, sometimes have the opposite effect. As medicine becomes more team-based and less hierarchical, some physicians may feel threatened. According to Matt Steinkamp, M.S.W., lead faculty for CPEP’s “Improving Inter-Professional Communications” seminar, “Physicians often tell me they have feelings of loss: loss of their role as a leader, loss of respect and prestige, and perceived loss of influence. These feelings can manifest as anger and frustration with their colleagues.”

By definition, the practice of medicine is a stressful endeavor, and stress can lead to friction on a medical team. Dr. Michael Yochelson, Chief Medical Officer at MedStar National Rehabilitation Hospital, notes, “As a physician leader, this is something you have to deal with perpetually, and it occurs with both attending physicians as well as residents. Sometimes the friction can be peer to peer, but other times it occurs between a physician and a nurse or even a patient. Unfortunately, physicians may be able to get away with behavior that other team members cannot. Many are highly trained in very specific sub-specialties and are difficult to replace.”

According to Steven Defossez, M.D., Vice President of Clinical Integration at the Massachusetts Hospital Association, “A busy work day or environment just accentuates a ‘head’s down’ focus on the task at hand and can heighten tensions with others. If you’re constantly in a hurry, you’re already set up for failure when it comes to inter-professional communication.”

Mr. Steinkamp agrees that time management, along with other factors, can complicate team dynamics. These include stylistic challenges, training issues and changes to the ways medical teams are structured. “Many physicians tend to be black and white, task-oriented, and can be perceived as ‘too direct,’ while nurses are often more process and relationship oriented. These styles can grate against one another,” Steinkamp reports.

Training issues, and the competitive nature of medical school and residency programs, may foster this “direct” style. Competitiveness, hard work and self-reliance are both required and rewarded, while teamwork may have been given a lower priority. When tempers flare, the words “I’m sorry” may be in short supply. Says CPEP’s Steinkamp, “Some physicians report apologizing is very difficult for them, and to some extent, have been trained not to as an admission of wrong-doing and an opening to liability.”

The Power of Relationships

In the face of these structural changes, Steinkamp suggests focusing on the “power of relationships” rather than on direct lines of authority. “Physicians can take steps to humanize themselves, bond with colleagues, educate vs. dictate, ask for input, and thus increase influence through ‘soft power.’”

Dr. Defossez adds, “You have to take the time to show you care about the people around you, and that can require trade-offs and motivation. Some individuals need to be convinced that by becoming more empathetic, effective communicators, they will in turn become more effective leaders. Interpersonal skills then become a useful tool, not just a ‘nice to have.’”

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, notes that embracing a team-based approach can lead to direct benefits for physicians. “Data shows that approximately 40% of physicians nationally report symptoms of burnout. An internal research group led by both physicians and nurses found that Mayo care groups that had a stronger team ethic reported reduced feelings of burnout, and thus greater job satisfaction.”

Strategies that Foster a Culture of Collegiality

Steinkamp encourages the use of team huddles as a way of assuring all hear the same thing at the same time and have an opportunity to get clarification. “You can’t just paper it over with a memo from the top. You need to lead by example and build these huddles into the daily schedule of medical teams – and then show up and engage. Scheduling huddles and then not attending can be more detrimental than not having a huddle to begin with.”

Dr. Defossez points to the Mayo Clinic’s primary value of “The needs of the patient always come first” as an example of a culture that promotes inter-professional teamwork. Dr. Wald agrees: “The Clinic was founded not only by the Mayo brothers, but also by the Sisters of St. Francis, who provided nursing and related care. The culture of mutual respect and partnership between physicians and staff was present from day one, and is still stressed today in every meeting at every level of the organization.”

Asked about team huddles, Dr. Wald notes, “These types of interactions are very common throughout the organization; some are formal, some informal. Pre-procedural/surgical huddles are a clinical requirement before any type of procedure, and all team members are encouraged to ask questions and make suggestions.”

Ed Eckenhoff, founder and president emeritus of the MedStar National Rehabilitation Hospital, maintains that the culture of teamwork is particularly strong in the rehabilitation hospital community: “We incorporate the team approach, where the entire clinical team meets together several times per week to discuss the patients’ successes and needs. It becomes this summary that assists communication between attending physicians, nurses and therapists. They all become quickly up–to-date with all aspects of patient care and appreciate each other as patient-centered team members.”

MedStar NRH’s Yochelson adds, “Health care in general is moving towards a model that rehabilitation hospitals have embraced since the 1940s. Our patients have unique needs. They require a team approach to care, and that close-knit, interdisciplinary approach is built into our training in residency. In other environments, physicians often talk to nurses, not with nurses. In the rehabilitation setting, that communication is more of a dialog and a two-way street. Nurses learn from physicians and vice-versa.”

The Challenge of Leadership

Dr. Yochelson continues: “These issues can be a real challenge to manage as a leader – nobody really likes, or wants, to deal with them. However, physician leaders have to resist the temptation to sweep these problems under the rug – they have to be dealt with in a serious manner. Leadership needs to sit down with the physician in question and be very candid; a physician may not have any idea how they come across, and that has to be made clear to them. Hopefully they will have the ability to change, although it may not happen overnight. These conversations may lead to education, coaching, or, if problems continue, discipline.”

“At MedStar NRH, we make it clear that regardless of title, all physicians are leaders and role models and are expected to act accordingly.”

About CPEP

CPEP (www.cpepdoc.org) is a 501 (c)(3) organization that promotes quality patient care and safety by enhancing the competence of physicians and other healthcare professionals in all 50 states from its offices in Denver, Colorado and Raleigh, North Carolina. CPEP offers focused courses on communication in the clinical environment, prescribing controlled drugs, and professional ethics as well as comprehensive clinical competence assessments.