Neurology and baseball

Teams fail when they cannot achieve a common goal. They also fail when they do not have one. In baseball, different goals between players and staff are unusual. Everyone wants to win. In neurology, where teams may be loosely defined and comprise people from many disciplines, goals differ. A win for you may not be a win for me.

In this issue of Neurology: Clinical Practice, Richie and Josephson¹ examine the adverse effects of team conflict, outline some of its drivers, and offer varied approaches to avoid or resolve it. They offer various means of conflict prevention such as creating an environment of trust. Building trust is accomplished by showing interest in one another and demonstrating appreciation and respect. Once conflict arises, the authors suggest an array of tactics: acknowledging and not ignoring it; demonstrating a calm, professional demeaner; deescalating tension; ensuring individuals are able to voice concerns; validating concerns; exploring solutions; and even encouraging constructive conflict and debate. Constructive conflict celebrates differences of opinion and rewards innovative thinking. Another useful strategy presented is aligning goals among team members across disciplines. Leaders can remind team members of their shared vision and goals. This last point is perhaps the starting place and core dependency of team success because teams without the same goals cannot be effective.

Defining and agreeing on a common goal is the most critical and challenging concept presented. Although it is important to agree on treatment plan goals as the authors suggest, a higher set of outcome-based goals may be the most effective way. Such goals, however, may presently be aspirational and difficult to understand, articulate, and implement. Defining the win is complicated in neurology, not easily distilled into a standard, universal metric. Nevertheless, the best chance teams have at aligning goals is to define and measure them through patient-focused interests and outcomes.

Health care has seen a rising interest in capturing goals, which revolve around concrete and measurable patient outcomes.^2–5 The creation of corresponding metrics, although well established in certain conditions such as Parkinson disease,⁶ does not exist for many others. Furthermore, they are inconsequential to neurologists and their patients not tracking or acting on them. Efforts by neurologists, largely represented by the American Academy of Neurology's quality measure sets,^7–9 aim to create common goals among all stakeholders by creating shared and measurable metrics. These sets may suffer from irrelevance to the frontline teams that variably use them for setting goals. To make them relevant, leaders of teams, clinical departments, and health care organizations can adopt outcome-focused goals and incentivize their use by frontline teams.

Perhaps equally as important as defining goals is defining the team. Its boundary extends to each person working to achieve the common goal, which should be the best possible patient outcome. Examples from the authors include an obstetrician for an epilepsy patient, multiple providers in amyotrophic lateral sclerosis multidisciplinary clinic, and the psychiatrist and primary care provider for an elderly inpatient with dementia. On an inpatient team, for example, a complex array of various disciplines orbit (or chaotically float around) the core physicians. Conceptually, the team may also include the transferring hospital, receiving ambulatory provider, patient, family, and friends. This varied group typically does not easily communicate with one another, work together, or articulate a common goal. Incentives, remunerative or otherwise, may not align.

The authors also describe how conflict can be productive, such as when neurocritical care providers debate the blood pressure target after cerebral hemorrhage. Even if perceived as a negative interaction, such a debate may help realize a common objective. These interactions can be tremendously beneficial between goal-aligned individuals. They cannot be constructive, however, without alignment. Here, the strategies the authors outlined would only address short-term problems. Similarly, the absence of conflict does not mean success. Team members may have simply failed to communicate at all. Alternatively, they may have never been aware of the other's existence such as the primary care doctor, obstetrician, and neurologist, all of whom should share a common patient goal and comprise the team in principle, but not in practice.

Conflict is best understood only after settling on membership, goal, and incentives. Otherwise, team breakdown and failure ensue. In baseball, a functioning club tries to win. All agree that winning is the goal. They execute their job and they win. They will not enjoy such success, for example, if one hitter's primary goal is to hit home runs, another is to steal bases, and only some are principally driven to win games and championships.

The distribution of championship rings and financial rewards for winning baseball clubs extends beyond the players on the field, which creates intense alignment among the varied involved disciplines. Bench players receive rings. Coaches in the dugout, management in front offices, and medical staff get rings, too. Everyone with the common purpose, contributing to the win, is part of the team.

In neurology, clinical outcomes may drive some people. Others may be driven by low or high clinical volume, schedule intensity, or intellectual stimulation. Furthermore, each driver may result in different financial incentives. Worse, there may be inconsistent goals and competing incentives across the entire clinical team. Neurologists alone, therefore, cannot successfully manage goals and conflict for the whole team. The presence or absence of conflict is influenced by the core clinical team, but even more by the organization and system in which the team exists.

Author contributions

Drafting/revising the manuscript.

Study funding

No targeted funding reported.

Disclosure

A.B. Cohen consults for Pear Therapeutics and Thirty Madison and holds stock options in Thirty Madison. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.