Why the office is not a team

‘Of all the habits of mind modeled in schools … the pursuit of community may be the most important.’

(Grossman, Wineburg, and Woolworth)

Teams are touted as the solution for many of the deficiencies in primary care — from chronic staffing shortfalls to employee burnout to patient apathy and discontent. But true teams — where members spend time together, know each other, challenge and learn from one another, and share responsibilities — are rarely found. In a word, teams are built on relationships. This article examines the forces that favour and discourage team building, and calls for a return to an office culture that fosters our founding values.

CONTEXT

Ambulatory care offices in the US are a beehive of activity. An operational diagram looks something like this: A patient of Dr Jones’s — older, say, with type 2 diabetes — is notified that his doctor has retired. He is assigned to a team. The core of that team is the medical assistant (MA)—primary care provider (PCP) dyad. It provides the basic and necessary screenings, prescription refills, and care coordination. But the team also includes an urgent care clinician for acute illness or trauma, a clinical pharmacist for HbA1c levels above 9.0%, a behavioural therapist for an abnormal depression survey, and a registered nurse for the Medicare Annual Wellness Visit. Surrounding them — anonymously, invisibly, and unaccountably — are patient service representatives (PSRs) who answer the telephone, schedule appointments, make referrals, prep charts, code billing, and sort the medical record. The endocrinologist, nephrologist, cardiologist, neurologist, and ophthalmologist each take their turn. Everyone has a task, but no one directs them. Once a protocol is activated or a referral is made, the system takes on a life of its own. Staff communicate with each other through entries ‘dropped’ into the electronic health record. But it is doubtful if anyone reads them, and orders fall through the cracks. Such a system is no more a team than are passengers on a bus, each co-located and heading in the same direction but with a different destination in mind.

CHECKLISTS AND UNFORESEEN CONSEQUENCES

In 2009, the surgeon and author Atul Gawande published the The Checklist Manifesto: How to Get Things Right. Its key insight is that, when complex procedures are broken into small steps and completed in a precise order, complications can be avoided. A case in point is the insertion of central line catheters. Prior to 2001, infection rates were common and resulted in a fatality rate of 5%–28%. Peter Pronovost, a critical care specialist at Johns Hopkins Hospital, set about lowering those rates. He introduced a five-point checklist that required doctors to 1) wash their hands with soap, 2) clean the patient’s skin with an antiseptic, 3) drape the entire patient, 4) wear a sterile cap, mask, gown, and gloves, and 5) place a sterile dressing over the insertion site once the catheter was in place.

With one simple protocol, the 10-day infection rate dropped from 11% to 0%. Within months, the checklist was successfully applied to the insertion of endotracheal tubes, urinary catheters, prosthetic joints, and beyond. But unforeseen consequences arose. The checklist led to an overuse of prescribing and imaging studies. It worked poorly where multiple problems coexisted. It lacked flexibility and contingency. Where rewards were tied to its adoption, gaming occurred. And when no one was looking, it was ignored.

Nevertheless, primary care offices adopted the checklist as a means to record demographic data, screen for depression, up-code billing charges, and organise the office note. A kind of linear thinking developed whereby clinicians based their assumptions on the previous step. Gone was a sense of narrative, whole-person understanding, curiosity, and the bubbling up of surprise and wonder. Staff and clinicians became data-extraction machines.

BUCKET BRIGADES

In the early 2000s, Nicholas Christakis and James Fowler began studying social networks within the Framingham Heart Study. They learned that the likelihood of someone becoming a smoker or drinker, growing obese, getting divorced, feeling lonely, or finding happiness was deeply influenced by their partner and friends. And not only their friends, but their friends’ friends’ friends — up to three degrees of separation. A social network is a group of people who are, to varying degrees, connected to one another. Within it, the strength and number of ties between members is more important than the individuals themselves. They shape the network, and are shaped by it, through the forces of connection (who is connected to whom) and contagion (what flows across the ties). One example of a social network is the bucket brigade, where a bucket of water is passed from person to person. No one member is connected to more than two others, and there are multiple opportunities for water to spill. The brigade fits the simple definition of a team — ‘a group of people working together to achieve their goal’. It is the model most often employed in ambulatory practices, where the bucket is the patient and his or her chief complaint.

While humans can work in large social networks, the capacity for friendship and teamwork is much more limited. It relies on our ability to track social relationships. Robin Dunbar, a British anthropologist, has estimated that, throughout history, the optimal group size is 150 or less, which represents the maximum number where one can know who is friendly or hostile and how they are related.

THE PROFESSIONAL COMMUNITY

In 2000, Grossman, Wineburg, and Woolworth published a study in which they recruited two dozen high school teachers to write a humanities curriculum. They were diverse in background, race, and gender; most came from English and history departments. Over the course of 3 years, they met biweekly after school, attended a day-long seminar each month, and participated in a 5-day retreat each summer. Initially they were a ‘community by declaration’, a pseudo-community whose members act as if they all agree. Whatever conflicts arose were grumbled about in private. The sociologist Erving Goffman describes this behaviour in theatrical terms: there is a front stage of public persona, a back stage of private reality, and a curtain between them of norms and etiquette. Over time a shift in group dynamics was observed. Participants began to speak of themselves not as individual educators but as members of the study group. They were able to vocalise differing opinions about group process, textual interpretation, and the shape of the emerging curriculum. And as they listened to each other, they incorporated their opinions into the group’s creative process. According to the authors, the key elements in the group’s formation were 1) adoption of a group identity, 2) handling of disagreements through new norms of communication, and 3) individual responsibility for the growth of others. Tensions remained, but members were increasingly inclined to resolve them through consensus and compromise. They viewed the group as an opportunity for learning in a pluralistic setting, and they viewed themselves as ambassadors for the group in the wider community. Transformation did not occur spontaneously. It required sufficient resources to guarantee a regular time and place to meet, and a safe environment where individuals felt ‘free to voice uncertainty, explore ideas, state and retract opinions’. It also took time for a new kind of leadership to emerge. ‘Leadership’, the authors concluded, ‘is not a personality trait but an attribute self-developed in social relationships.’

Of all the habits of mind modeled in schools, the habit of working to understand others, of striving to make sense of differences, of extending to others the assumption of good faith, of working toward the enlarged understanding of the group — in short, the pursuit of community may be the most important.

OBSTACLES AND OPPORTUNITIES

If a diverse group of teachers can become a professional community, why not an ambulatory medical practice? The challenges are daunting: High staff turnover makes it difficult to accumulate shared memories. Policy decisions are made by absentee landlords who accept the high turnover rate as the cost of doing business. Within the practice itself, job descriptions are too narrow, staff too busy, to work toward a collective vision. It is easier to retreat into our exam rooms and bury ourselves in the Electronic Health Record than contribute to the hard work of building community. For as St Benedict (480‒550 ce), the founder of Western monasticism, wryly observed: ‘Living in community is all the aestheticism you need.’

An office that runs mechanically is better off than one that doesn’t run at all. But why stop there? Could we thrive in a setting where staff learn from each other, feel supported, assume responsibility, listen authentically, and accept our differences as an asset rather than a liability? It would require us to keep staff size small and work side by side, cross-train whenever possible, hold meetings that provide time for self-reflection and shared problem solving, offer feedback to one another, and make decisions that are informed by those who are directly affected by them.

CONCLUSIONS

I know how difficult it is to run an office. I have endured staffing shortfalls, patient complaints, and collegial grumbling about night call and documentation. I know that quick fixes are in short supply. Teams can solve some of our problems, but only if we regard ‘the team’ as an office of long-serving, self-motivated, and well-connected employees. Checklists and bucket brigades are simply tools. They can simplify and economise the more mechanical aspects of doctoring, but they are useless in the aid and comfort of those who need it most: older patients, the anxious, depressed, addicted, and lonely. And that other person in the room, the doctor. The social nature of human activity is as old as our species. We are instinctually altruistic, trusting, story tellers and listeners; we lead when leadership is required. We need our peers to see beyond the blinders, compensate for our idiosyncrasies, and support us when the going gets tough. That is the real miracle of the team, not that it can transport water across a distance.

The most important habit of mind in a primary care office has nothing to do with rooming a patient, conducting a screening survey, or up-coding an office visit, no matter how important these are to running a business. Even ‘patient safety’ and ‘customer service’ are the byproduct of something more fluid and ephemeral. Of all the habits to which we put our minds, the pursuit of community is uppermost. To believe it is an act of faith — a faith in the human potential, and in our relationships at work — the cornerstone on which family medicine was founded.