It Takes a Village: Making the Case for Teamwork
Drs Louise King, Camran Nezhat, and Paul Wetter discuss an effective teamwork model, agreeing that patients have better outcomes when clinicians work as a team.
As rounds began on an inpatient floor early one morning, a team of surgeons rushed in to visit a fragile 75-year-old woman. The attending surgeon, too busy to think of the patient, abruptly told her, “Your MRI shows you have colorectal cancer, so we plan to take you to the OR for surgery tomorrow. Alright, see you later,” he said, rushing out of the room just as fast as he arrived. But Ms. A, who had been resting on her hospital bed, reacted with fear and confusion. A nurse noticed her immediately turning pale after she heard those words from the attending. She tried to open her mouth, but the gravity of the news she had just learned left her speechless. Finally, she slowly raised her shaking arm and squeezed out a few words, “I … I don’t … understand.” But by then the entire surgical team had left.
Six and a half hours later, a nurse ran into the surgery dictation room, angry and determined, “Who is Ms. A’s doctor? Did you guys know she has depression, and today is the first time she’s heard she has cancer? She just attempted suicide by cutting her wrist in her room!”
The team reacted with silence. “Well, I thought somebody had already told her,” said the attending, while scrolling down numerous progress notes in the electronic record. “Aren’t GI, oncology, and ID all on board for her case?”*
*This incident did not occur at any of the hospitals mentioned in this article.
We have heard “teamwork” uttered throughout the GYN community for at least 10 years, especially since 2004, when a Sentinel Alert issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures. As a result of many difficult cases such as this one, it was recommended that hospitals implement teamwork training programs in an effort to improve communication and outcomes.
As the case example illustrates, simply forming teams is not the answer; it is a pointless exercise unless there is a good plan with effective implementation. Teamwork means many things and, too often, it is applied superficially. What is needed is effective teamwork for the benefit of everyone involved, especially the patient. So, ten years after the Joint Commission issued their recommendations, how is the industry doing? How can we improve? And, most importantly, in 2014, what can we take advantage of so that incidents such as these do not recur?
Certainly hospitals have implemented required training, but some training programs amount to only a few hours of lecture. Let’s look at another model that can help develop an improved program for both multidisciplinary and internal teams.
What Are Teams for, Anyway?
[[{"type":"media","view_mode":"media_crop","fid":"25180","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8880718767177","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2264","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"144","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Louise P. King, MD, JD","typeof":"foaf:Image"}}]]“Every single time I interact with my team, it is beneficial,” says Louise P. King, MD, JD, gynecological surgeon at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School. “The more we work with the same people, the more we learn and the better we’ll do.” King says the most significant benefit to effective teamwork plays out in everyday interactions that lead to better overall care. At Harvard, she says, “The operating room roles are very important. I’ve learned a great deal from other surgeons. Through effective communication, checklists, protocols, and standards of practice executed daily by teams that work together help us provide excellent care.”
She remembers a particular case earlier in her career at another hospital where she had a larger team come together during a complex surgery. “The patient did so well she actually went back to work three days later-because our team, made up of great people-helped us to get it done well.”
King also mentions psychiatric patients she attended to earlier in her career, people with developmental delays and borderline personalities, who presented special challenges that required a team approach. “When I began practicing, working with psych patients was challenging.” But she learned early on how to work with them through their frustration. She reaches out to the hospital’s psychologists/psychiatrists, who serve also as social workers. “I learned from them about how to respond in this special situation.” She says they will team with her to talk to the patient, saying things like, “This doctor is trying to help you.” King has learned how to respond in difficult circumstances. “I realized that if I don’t have a particular way to address the issue, I’ll turn to these professionals.”
Forming the Right Team
[[{"type":"media","view_mode":"media_crop","fid":"25183","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5778944159392","media_crop_h":"292","media_crop_image_style":"-1","media_crop_instance":"2263","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"122","media_crop_w":"237","media_crop_x":"0","media_crop_y":"31","style":"line-height: 1.538em; float: right;","title":"Camran Nezhat, MD","typeof":"foaf:Image"}}]]“We certainly learn from each other,” says Camran Nezhat, MD, chair of Association of the Adjunct Clinical Faculty at Stanford University School of Medicine and an adjunct clinical professor of OB/GYN and surgery also at Stanford University. “Progress takes place when there is collaboration between different disciplines.” Nezhat says it is as if the other specialists are handing you some of their experience. He adds that it’s more than the communication-it is about the relationships you have with other physicians.
Nezhat also advises sitting down and talking with the team prior to surgery. “Have an honest and frank discussion.” He follows up by having the patient meet the other physicians in person. He, too, recognizes the contribution that every team member makes. “When I work with Mark Welton and Andrew Shelton of our colorectal team or Ben Chung and Harchy [Harcharan] Gill from urology, for example, there are better outcomes-because their skill adds to my abilities and, together, we really help the patient.”
[[{"type":"media","view_mode":"media_crop","fid":"25197","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_2483318890444","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2274","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: left;","title":"Mary Lou Ballweg","typeof":"foaf:Image"}}]]Mary Lou Ballweg, president of the Endometriosis Association, speaks with surgeons almost daily about the complexities of endometriosis, which she calls “a specialty disease.” She says the reality is that, because of the lack of knowledge-sharing, the patient is often set up for multiple surgeries. “This is not an acceptable solution,” she says. “We can address the problem of diagnosis and treatment much better with teams.”
Ballweg reasons that multidisciplinary teams serve as a check-and-balance system, where surgeons can learn the very best from each other. “Not every hospital can bring together the right people. Patients need GYN specialists working side by side.” Her experience has taught her that patients need the right team working together, and there are times when “rebuilding teams” needs to be considered.
Nezhat makes the same point. “I’m always respectful, yes, but it is better to work with a colleague that you like and admire.” He says that if you are working with a team you don’t enjoy or you disagree with, it can cause too much stress for both sides, and the patient doesn’t benefit. Nezhat also advises administration to provide the best available equipment for the team to ensure success. “I cannot play the piano without a piano or with a broken piano.” There is new technology that can help teams operate better.
Upcoming Technology
[[{"type":"media","view_mode":"media_crop","fid":"25182","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1318221213296","media_crop_h":"268","media_crop_image_style":"-1","media_crop_instance":"2265","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"117","media_crop_w":"209","media_crop_x":"5","media_crop_y":"4","style":"line-height: 1.538em; float: right;","title":"Paul Wetter, MD","typeof":"foaf:Image"}}]]Paul Wetter, MD, chairman of the Society of Laparoendoscopic Surgeons, is working on using brand-new technology to accommodate teams in surgery nationwide. He is working with academic centers to develop technology that will help surgeons track, monitor, and diagnose patients better and more quickly.
“Every patient has a super computer in their pocket with an infrastructure that allows for progress in medicine,” says Wetter. “For example, studies could be conducted via cell phones. We’re asking how we can work together to help each patient-all we need is the right kind of application where multi-disciplinary teams can come in and make all the difference.”
According to Wetter, this is the future of team surgery. In real time, patients could be tracked to identify the hotspots in the body. The surgical team can compare notes and talk with each other. This doesn’t exist today. But it is the future. We’re just beginning to think of all of the possibilities. “We are right on the cusp of technology that will change everything,” he says.
At Stanford, Wetter is working with senior fellows who are studying endometriosis so that they are better exposed to other specialties. “Stanford is the first institution to adopt our new one-year program,” he says. “This new multi-specialty approach will improve training so that physicians can more easily coordinate and set up multidisciplinary teams. We are working on the best way to bring new technologies to teams.”
However, the very best technology won’t make a difference if team commitment and structure is lacking. Wetter advises us to put safety and cost considerations first, without compromising quality. “What is critically important is that physicians talk and share records.” He adds, “We need to continue to develop systems that foster cooperation, systems that encourage second opinions.”
But how can this be accomplished? Primary care physicians know a lot, but they are not recognized for their knowledge across disciplines. Like most physicians, their biggest fear is what they don’t know. Teams alleviate this fear and help each physician acquire knowledge. Nezhat likes to encourage his fellows with the advice that in order to conquer this fear, teams must have mutual respect for each other.
Learning from Hindsight
Later on, “Ms. A” was rescued and stabilized from her suicide attempt. Had there been a better team building program, improving the communication of each multidisciplinary team, there wouldn’t have been an incident. The buck wouldn’t have been passed. The patient’s life wouldn’t have been in danger. We are becoming more specialized, and for that very reason physicians need to become better communicators, verifying, verbalizing, and each time noting the history of the patient.
“Think of everyone else in the OR as an important member of the team. You will do a much better job getting feedback and help from them,” says Wetter. “All those professionals have information that could, in some ways, help you.”
References:
For more information:
http://www.emeraldinsight.com/journals.htm?articleid=17095307
http://www.european-hospital.com/en/article/11130-UK_Multidisciplinary_teamwork_will_stay.html
http://patientsafetycouncil.org/uploads/Multidisciplinary_teamwork_and_communication_training.pdf
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