Although doctors look after their patients, they don’t always look after each other.
What has happened to collegiality? Why are doctors so unkind to each other? Anaesthetist Dr David Brewster and surgeon Dr Bruce Waxman ask these questions in the Medical Journal of Australia.
The authors are of the opinion that doctors have become too judgemental of their peers and that constant negative commentary has affected the workplace environment.
They write: “We have all been guilty of uttering critical colloquialisms in the workplace that resist positive interdisciplinary relationships. Unfortunately, our apprentice junior doctors adopt these expressions that promote lack of collegiality. Doctors learn to criticise and blame each other, rather than understand the differences we all face in providing the best care to our patients.”
Kindness can be as simple as saying thank you or acknowledging the work of a colleague, and a smile or a cup of coffee also go a long way, they argue.
Reading this in our medical journal gives me hope. It is not easy to discuss this topic publicly in a highly judgmental culture.
Collaboration can be very rewarding. It is often talked about but not easy to achieve, and it doesn’t always make the top of the priority list.
Although it’s not the solution to everything, effective collaboration can be a source of satisfaction and has the potential to make work, and life, more fun. Of course, collaboration does not mean that we have to agree on everything.
I’d like to share some thoughts on the ‘ingredients’ of successful collaboration:
#1: Letting go of control
No one is as smart as all of us, said Ken Blanchard. It’s ok to not have all the answers. In collaborative cultures outcomes are largely dependent on organic group processes. It is important to empower others and trust in the wisdom of the group and diversity of thought.
#2: Celebrating diversity
Interesting things happen when people bring different backgrounds, disciplines, skills and ideas to the table. We need to be open to a dialogue that celebrates differences. This is not always easy as our tendency is to engage with like-minded people.
Diversity improves decision-making as it stimulates critical evaluation and prevents groupthink. Diversity also means accepting that we can have differences of opinion.
#3: Aiming for mutual benefit
In collaborative cultures mutually beneficial solutions become more important than winning and personal gain. We need to attend to the needs of all parties and not just our own.
Consensus improves the quality of decision-making through genuinly addressing individual concerns. Asking questions and finding out what outcome the other party needs is key to finding common ground for agreement.
#4: Formulating shared values or goals
Often we want to jump to the ‘how’ without having explored the ‘why’. Universal values are motivating! They answer the why question and are the reason we get out of bed in the morning. Providing excellent care to our patients is an example of a universal value/goal most of us share.
#5: Building relationships
If we focus on outcomes without investing in relationships, there is a good chance that we will fail. Building trust and relationships are key components of effective collaboration. This is never a once-off tick-box exercise but should be an ongoing activity.
Immature tribal cultures create silos and distrust, and sustain undesired behaviours. How can we change a dominant culture and become more effective?
My mother spent years of her childhood in Tjideng, a Japanese internment camp for women and children run by the cruel Captain Kenichi Sone.
She was born in the former Dutch East Indies, now Indonesia. The Dutch occupied and exploited the country for over four hundred years, but in 1942 things changed dramatically as a result of the Invasion by the Japanese imperial army.
The women in the Japanese internment camps are sometimes called the ‘forgotten women’ of the war in the East. These camps, as well as Dutch colonialism, are some of the worst examples of tribalism.
Tribalism comes of course in many shapes and forms including, as we all know, in the medical world.
Tribes & organisations
Most leaders know that tribal cultures are a key factor in the performance of organisations. Some leaders are experts at creating close-knit cultures, but only a few can change a culture that doesn’t perform optimally.
Tribalism is the natural way we organise ourselves into social groups. Our ‘tribes’ are part of who we are. They offer support, security and a sense of belonging an there’s nothing wrong with that.
However, tribalism can also refer to a false sense of superiority, sometimes leading to exclusion, bullying and discrimination.
We can change a dominant tribal culture and upgrade our organisations to more collaborative, healthy stages. History shows that goal-oriented groups and organisations that work well with others are more successful.
5 tribal cultures
In the book ‘Tribal leadership’, Professor David Logan et al describe five stages of tribal culture. As he points out, the medical profession is only half way, at stage three of five.
Logan’s tribal stage one is the mindset of gangs and war criminals – people who come to work with weapons. There is hostility and violence and no cohesion.
People working in a stage two culture may have coffee mugs with slogans like: “I hate work,” or “I wish it was Friday”.
There is often a high suspicion of management and authority in general, and team-building efforts are not effective in this culture.
Stage three is the dominant culture in almost half of all organisations, including many professional workplaces. Quite often doctors fall into this category. In stage three it is all about personal success and being the smartest. Stages four and five are the collaborative cultures.
Let’s have a closer look at the most common culture, stage three.
I’m great (and you’re not)
The mantra of stage three is ‘I’m great’, often followed by the unspoken words ‘and you’re not’. There’s a long history in medicine of stage three cultures with a strong focus on individual expertise and success.
One of the earliest examples I could find is this well known Rembrandt paintingtitled, ‘The anatomy lesson of Dr Nicolaes Tulp.’
Dr Tulp was a highly respected surgeon in Amsterdam in the seventeenth century; he is clearly the central figure in this painting. He’s the only one wearing a hat. Sadly but not surprisingly there are no women present.
You could argue that this scene demonstrates the dominant culture of the exclusive Amsterdam Guild of Surgeons. These days, almost four hundred years later, the dominant culture in medicine hasn’t changed all that much.
Professionals working in a stage three culture are often very good at what they do as individuals but what they don’t do is bringing people together.
They may think they are. Interestingly people in stage three often think that they are at one of the collaborative stages. They may talk about collaboration and teamwork – hallmarks of stage four and five – but their actions firmly put them in stage three.
The issue with a stage three culture is that it cannot be fixed – it can only be abandoned. The solution is to move your tribe to the next stage, stage four.
How to upgrade
People working in a stage four culture don’t talk about themselves. They first start listening. It’s no longer about being the smartest or about personal success.
There’s a move from ‘expert’ to ‘partner’. The language used is not “I’m great” but “We’re great”. There’s tribal pride.
Eventually, later in stage four, organisational boundaries become less important and cross-pollination between organisations may occur.
So how do we upgrade our culture from stage three to the more collaborative stage four? Logan describes several principles, including:
Focus your team on tribal success instead of personal success
Point out the superior results of stage four tribal cultures
Describe role models in the organisation that show stage four behaviour, for example people who are talking about ‘we’ instead of ‘me’
Encourage transparency and sharing of knowledge & information as much as possible.
There’s one main problem with stage four, reflected in the unspoken sentence that often follows “We’re great,” and that is: “… and you’re not,” referring to other groups or organisations. That’s where stage five comes in.
Stage five is the dominant culture in two percent of work places. In this stage there is no ‘they’.
‘Them & us’ thinking has gone out of the window and there is a focus on inspiring purposes. These are often universal values, taking away the need to compete.
People working in stage five cultures can work with any group that has a commitment to universal core values – even if these values are different from their own.
More collaboration in medicine has many benefits, including for direct patient care, mental health of doctors and healthcare reform.
We always talk about leadership but effective followership is just as important.
Effective followers don’t blame their leaders when things don’t go as planned; instead they offer support and gently, but persistently, steer their leaders in the right direction to help them achieve the organisational goals.
What the medical profession needs is people who build bridges.
I’d encourage you to review your own organisation(s) and look for opportunities to collaborate. Don’t accept non-collaborative cultures.
Find role models and like-minded people, people who talk about ‘we’ instead of ‘me’, and together take your dominant culture to the next level.
This is an adaptation of a presentation given at GPDU18.
When I was preparing this session I thought I’d start by telling a joke:
Five doctors went duck hunting one day. Included in the group were a general practitioner, a pediatrician, a psychiatrist, a surgeon and a pathologist.
After a while, a bird came winging overhead. The first to react was the GP who raised his shotgun, but then hesitated. “I’m not quite sure it’s a duck,” he said, “I think that I will have to get a second opinion.” And of course by that time, the bird was long gone.
Then another bird appeared in the sky. This time, the paediatrician drew a bead on it. He too, however, was unsure if it was really a duck in his sights and besides, it might have babies. “I’ll have to do some more investigations,” he muttered, as the creature made good its escape.
Next to spy a bird was the sharp-eyed psychiatrist. Shotgun shouldered, he was more certain of his intended prey’s identity. “Now, I know it’s a duck, but does it know it’s a duck?” The fortunate bird disappeared while the fellow wrestled with this dilemma.
Finally, a fourth fowl sped past and this time the surgeon’s weapon pointed skywards. BOOM!!
The surgeon lowered his smoking gun and turned to the pathologist beside him and said: “Go see if that was a duck, will you?”
The tribal jungle
Two years ago our keynote speaker was the amazing Dr Victoria Brazil, emergency physician and medical educator from the Gold Coast. She spoke about tribalism in our profession and said:
“I think we actually work in a tribal jungle in healthcare.”
She was right. We make jokes about the characteristics of the other tribes, like I just did, but tribalism is still one of our biggest challenges today. We are concerned about fragmentation in healthcare – but what about the divisions within our own ranks?
Part of what makes general practice attractive is its diversity, but it is also a weakness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice versus corporates, rural versus metropolitan etc.
I’m not saying we should be one big happy family, but why not focus more on what we have in common?
There is hope: participants of groups like United General Practice Australia and, here in Queensland, the GP Alliance, have shown a desire to put aside tribal differences and work towards common goals. This is a start, and initiatives like these must further strengthen the voice of general practice in the near future.
Investing in general practice
With the Federal Budget due to be handed down this coming Tuesday, this weekend also serves as a timely reminder of the RACGP’s advocacy campaign to reverse the freeze on Medicare rebates. As part of our pre-budget submission to the Federal Government, we outlined 4 key strategies that will improve quality-led patient care.
In order to provide quality healthcare services, MBS rebates must be in line with the cost of doing so. More than 80% of the Australian population is seen by GP’s each year but only 8% of Government healthcare spending is allocated to general practice.
New data presented in the flagship report from the National Health Performance Authority released this week, shows that people who do not see a GP have a 30% higher chance of visiting an emergency department.
Investment in primary care will result in long-term health savings and reversing the freeze on MBS indexation is a must. The College will continue to represent our members and lobby the government on this very important issue.
The theme of this RACGP Queensland Conference is ‘the future’. So here’s a challenge for you:
You don’t have to go duck hunting with your colleagues, but what can you do to reduce tribalism?
If you decide to take up this challenge, do one thing, one little thing, and start this weekend while you are amongst your peers.
If we want the future to be different, if we want to see different results, we should do things differently.
Many GPs feel disempowered in the current climate of cuts and freezes. It is indeed hard to comprehend why governments slash funding to the most efficient and cost-saving part of the health system.
We are all concerned about the lack of continuity of care and increasing fragmentation in our healthcare system, but what about the divisions within our own ranks?
Part of what makes general practice attractive is its diversity, but it also makes general practice prone to divisiveness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice vs corporates, rural medicine vs metropolitan general practice, etc.
GPs are highly respected in the community, but have become an easy target because of marginalisation and fragmentation. It is a well-known secret that governments play different GP groups off against each other, choosing to include or ignore organisations in their deliberations and negotiations.
Lack of unity also opens the door for disruption by third parties.
It is clear that general practice needs an urgent cultural change. Just like surgeons are working on improving the bullying culture, we must address the disharmony and division that afflicts us.
How good would it be if practices worked together instead of competing? If GPs could get together and agree on issues important for their area? If peak bodies would team up and better coordinate strategy, policy development, campaigns, conferences and membership services?
There is a whole generation of GPs that don’t understand why we have so many representative organisations. These young doctors are concerned about the disadvantages. Why don’t general practice organisations support each other, why are there multiple memberships and so much duplication? I believe they are right.
We have much more in common than what sets us apart, so why are we so tribal?
I can think of a few reasons. The first that comes to mind stems from social psychology; our brains may be programmed to organise us into small tribes because of evolutionary advantages, such as social bonding and survival.
There are also economic motivations, for example, GP clinics currently compete for patients. Our peak bodies are based on membership and need to offer benefits; this encourages competition rather than collaboration.
Reform fatigue may be another reason why some of us have stopped caring about achieving common goals. Experienced GPs can tell us the tales of the many system changes they have witnessed over the years; reform comes and goes and often disrupts our day-to-day practice. The risk is that we become cynical about what our profession can achieve in Canberra.
Perhaps there is also a selection bias. It is possible that GPs prefer more autonomy than our hospital colleagues, and although we work increasingly in teams, we may be less group-oriented or prefer smaller tribes.
Finally, doctors are trained to be leaders. We’re masters in problem solving and good at making difficult decisions, often in challenging and stressful situations.
We’re independent thinkers, skilled at arriving at our own conclusions and giving strong opinions. But we are not a profession of followers. The success of organisations depends on how well their leaders lead and how well their followers follow.
United General Practice Australia (UGPA) could connect the dots here. It’s an umbrella group for all the main groups, including the RACGP, ACRRM, AMA, RDAA. Those taking part have shown a desire to put aside their differences to a certain extent.
However, the status and governance of UGPA is somewhat vague. There is also no website or official spokesperson. But it is a start, and I would love to see this organisation be given the opportunity to grow and represent us all.
Lastly, we need to find common ground and partner with patient health organisations, as governments listen to the public more than they do to doctors.
The time has come to stop and think about where we want to go. More unity would require a cultural shift, excellent skills in following others, trust and willingness to compromise — not just from our leaders, but from all of us.
This article was originally published in Australian Doctor Magazine.
It appears the new Primary Health Networks (PHNs) are here to for the long haul. There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community.
RACGP Queensland has developed a draft position statement identifying 4 concrete targets that should be aimed for in primary healthcare reform at a local level.
The targets are presented below. I believe that PHNs could play an important role in achieving these goals – in collaboration with GPs.
PHNs are in an excellent position to assist healthcare providers and organisations to build effective relationships. PHNs should facilitate a shared health vision for their local area, exceeding disciplinary and organisational boundaries.
PHNs should encourage continuity of care and make sure new models and initiatives do not further fragment our health system and/or adversely affect health outcomes.
PHNs need to play an important role in facilitating better information exchange and communication between healthcare providers.
PHNs should encourage the development of innovative models of care that introduce genuine integration between the various parts of the health system.
As frequent readers of this blog may know, I am very unimpressed with the recent pharmacy agreement negotiated by the Pharmacy Guild of Australia. We need more teamwork and integration of health services, not fragmentation, and therefore it’s a real shame the Health Minister has signed off on this deal with the pharmacy owners union.
A better proposal has come from the Pharmaceutical Society of Australia (PSA) and the Australian Medical Association. For those who don’t know: The PSA represents Australia’s 28,000 pharmacists working in all sectors and across all locations. The new model encourages close collaboration between pharmacists and GPs.
The PSA and AMA recommend integration of non-dispensing pharmacists in general practice, to improve medication management. The idea is not new. Doctors and pharmacists have argued for this model in the past. There is enough evidence to support collaboration as a way to improve patient care.
Here are the aims of the cooperative model:
Medication management reviews conducted in the practice, an Aboriginal Health Service, the home or a Residential Aged Care Facility
Patient medication advice to facilitate increased medication compliance and medication optimisation
Supporting GP prescribing
Liaising with outreach services and hospitals when patients with complex medication regimes are discharged from hospital
Updating GPs on new drugs
Quality or medication safety audits
Developing and managing drug safety monitoring systems.
Medication reviews by a pharmacists in the hospital do not appear to reduce mortality or hospital readmissions, although they seem to reduce emergency department contacts. Similarly, medication reviews for nursing home residents do not to reduce mortality or hospitalisation – which is disappointing.
However, in these studies pharmacists and doctors are not working closely together as suggested by the PSA and AMA. This matters because studies have shown that doctors are more likely to change their medication management when there is a close collaboration with a pharmacist. This is not surprising as the basic requirements for effective teams are mutual trust, good communication and shared ideas.
A systematic review of pharmacists working in collaboration with GPs showed significant improvements in blood pressure, diabetes control, cholesterol levels and cardiovascular risk. Another review suggested similar benefits as well as a positive impact on drug-related problems.
A recent trial confirmed that pharmacists working in primary health clinics are succesful in identifying and resolving medication related problems and improving medication adherance. The PINCER trial concluded that pharmacist feedback, educational outreach and dedicated support in a general practice setting was cost-effective and reduced medication errors.
Whether the pharmacist-doctor partnership reduces hospital admissions is less clear-cut. An independent analysis by Deloitte Access Economics (commissioned by the AMA) suggests that every $1 invested in the PSA-AMA model would generate $1.56 in savings to the health system, delivering a net saving of $544.8 million over four years.
I spoke to Dr Steve Wilson, Chairman of the AMA (WA) Council of General Practice and senior Lecturer at the School of Medicine, University of Notre Dame.
“We recognised the need for, and the advantage of, having pharmacists within the practice team,” says Wilson. “We have looked at both sides of the coin, the good and the bad, advantages and risks. We have explored the various financial models, for example whether pharmacists should be employed directly, or contracted, and whether to follow the Practice Nurse incentive Payment model or the Mental Health Nurse model.”
Dr Wilson said the strengths of the proposal are:
Quality use of medications as over-arching principle
In-house reviews as opposed to out-of-house
Medication interaction checking
Reviewing the currency of medications, for example deleting old antibiotics still on the list
Screening for adverse medication events or omissions such as whether medications can be reduced or stopped, or whether certain checks have been performed
Checking currency of tests, for example renal function for those on diuretics
Explaining medications to people, for example what side effects to look for
Working with those from culturally and linguistically diverse people or a non-English speaking background, people more than five medications, people with early cognitive impairment etc
Quality Use of Medications meetings within the practice, attracting CPD points
The Pharmacist in General Practice Incentive (PIGPI) system would be structured in the same way as the existing incentive payments provided for nurses working in general practice.
Dr Wilson: “The risk of the program is low, it’s voluntary, doctors and patients don’t have to participate. It’s up to the GP practice to make it work and customise it to their circumstances. There are financial incentives for rural practices. Also practices can share a pharmacist, particularly when closely located to one another.”
“The evidence will build over time. The evaluation component will require input from hospitals and there may be a role for the Primary Health Networks and Local Hospital Networks.”
The proposal has been welcomed by the Consumers Health Forum (they’re requesting feedback here). Although there are clear benefits for patients, evidence-based medicine purists may argue that the evidence for cost-savings through a cooperative model is thin. However, the alternative may be no change at all.
Traditionally campaigns against poorly thought-out Government policies have predominantly been doctor-centric, and the usual Government response is to divide consumer and medical organisations.
Jen Morris is a patient advocate and researcher in healthcare quality and safety at the University of Melbourne. She feels strongly that cooperation is required if we want to make more impact in Canberra.
This makes sense. It looks like the time is right for a novel approach – and it is much needed too, as the discussion about healthcare so far has been about dollars instead of quality. What are the benefits of a patient-doctor alliance and how do we overcome our differences?
The numbers game
“At a strategic level, it’s a numbers game,” says Jen Morris. “There are approximately 26,000 GPs in Australia, and about 82,000 registered medical practitioners. But there are over 23 million patients. That is an enormous bloc of voters and lobbyists to leave untapped.”
“When campaigns are too doctor-centric, that leaves this bloc ‘in play’ – sparking a spin and PR war between doctors and the government, vying for public support. But if doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”
“More importantly, putting patients and their care at the centre of pro-healthcare campaigning recognises healthcare exists wholly for, and because of, patients. Sometimes, public debates amplify some of the worst features of traditional hierarchies in clinical healthcare. Authority figures argue over who knows what’s better for patients, and best represents their interests.”
“All the while, patients pushed to the sidelines quietly await a chance to speak for themselves. If we’re serious about changing the culture of paternalism in healthcare, and empowering patients, that change in approach needs to permeate right through from the consulting room to the campaign platform. ”
What if we disagree?
There may be topics where patients and health providers don’t agree, such as certain aspects about the PCEHR. This can really paralyse a project. How should we approach this?
Morris: “It is important to remember that disagreement doesn’t only pose an obstacle in ‘patients and providers’ scenarios. Neither patients nor providers are homogeneous groups, and we do well to remember that. It is worth asking how providers approach the problem when they disagree on an issue or project, and source lessons from that.”
“It’s worthwhile looking for points of common ground, and building upon those
“The possibility that some parties may disagree is not, for example, a reason to exclude likely dissenting practitioners from a committee of doctors. In the same way, it is not a reason to exclude patients from healthcare policy discussions. Moreover, the fact that patients and providers may not always agree is not a reason to close our minds to collaborating when we do.”
“We should approach such disagreement on policy and projects the way we should in any sector. That is, give relevant stakeholders of all perspectives a fair opportunity to be heard. And, where possible, try not to speak for others in lieu of them speaking for themselves first.”
“It’s worthwhile looking for points of common ground, and building upon those. More often than we acknowledge, patients and doctors are really advocating for the same outcomes. But too often we don’t take the time to really analyse where the crux of disagreement actually lies.”
“So it’s worth trying to identify when disagreement is about what the end goal should be, and when it’s about how we should best get there. That helps to clarify how the points of difference, and points to potential solutions.”
“In cases where viewpoints really do differ substantially, all parties should have the opportunity to make a case for their proposal, then let the policy and law makers evaluate those on their merits.”
Is there a will to cooperate?
Morris: “Because I don’t work for or represent a consumer organisation, I can’t speak for them with any authority. However, I will say that in my experience, there is reflexive and entrenched suspicion on both sides.”
“If we find that the aims of doctors’ and patients’ organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently
“Patient organisations are concerned about being seen to endorse a situation in which doctors’ organisations dominate and speak ‘on behalf of’ patients. Because such situations hark back to unhelpful, dictatorial hierarchies which have traditionally silenced the patient voice.”
“On the other hand, doctors’ organisations have expressed concern that patients do not understand the complexities of health policy and systems, the challenges faced by practitioners, and the broader potential consequences of proposals.”
“But in my experience, if and where these issues exist, it is in working together that parties learn from each about about how they can all do better. And the result is stronger organisations, and a more robust campaign.”
“It is healthy for organisations to remain vigilant about being faithful to their purpose and mandates. However, if we find that the aims of doctors and patient organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently.”
“As a patient advocate, I would be delighted to have the opportunity to campaign alongside doctors and their organisations when appropriate. And indeed, on several issues I have done just that.”
“I have the privilege of working alongside many doctors in my role, who have taught me a great deal about the everyday realities of being a doctor. And I am a better advocate as a result. I hope that working with patients and advocate affords doctors similar insights.”
Five doctors went duck hunting one day. Included in the group were a general practitioner, a paediatrician, a psychiatrist, a surgeon and a pathologist.
After a time, a bird came winging overhead. The first to react was the GP who raised his shotgun, but then hesitated. “I’m not quite sure it’s a duck,” he said, “I think that I will have to get a second opinion.” And of course by that time, the bird was long gone.
Another bird appeared in the sky thereafter. This time, the paediatrician drew a bead on it. He too, however, was unsure if it was really a duck in his sights and besides, it might have babies. “I’ll have to do some more investigations,” he muttered, as the creature made good its escape.
Next to spy a bird flying was the sharp-eyed psychiatrist. Shotgun shouldered, he was more certain of his intended prey’s identity. “Now, I know it’s a duck, but does it know it’s a duck?” The fortunate bird disappeared while the fellow wrestled with this dilemma.
Finally, a fourth fowl sped past and this time the surgeon’s weapon pointed skywards. BOOM!!
The surgeon lowered his smoking gun and turned nonchalantly to the pathologist beside him and said: “Go see if that was a duck, will you?”
What’s great about this joke is not just the stereotype behaviour of the five doctors – which most people working in healthcare immediately will recognise. What is wonderful here, is the different disciplines doing some team building. They may not be very efficient as a team yet, and they could have picked a different activity, but at least they have found a common goal: hunting.
In the real world of medicine we sometimes seem to have forgotten our purpose. The inconvenient truth is that we’re often acting as a dysfunctional team where every member’s main goal is to finish their own little task, and where other team members and disciplines are sometimes regarded as ‘the enemy’.
A while back I was privileged to hear Dr Victoria Brazil speak at a conference of the Royal Australian College of General Practitioners in Brisbane. Dr Brazil is an emergency physician and passionate about the topic of medical tribalism. Instead of the more primitive tribal behaviour – characterised by hostility towards other tribes and the unwillingness to take responsibility for a bigger cause – we should move to a kinder tribalism driven by mission and purpose, without common enemies, she argues.
Dr Brazil reminds us that we cannot achieve the best patient outcome without other disciplines. Building relationships, communicating and networking are the key to success. This sounds obvious but it’s not very often that we make time to sit down and have a yarn with members of other teams.
You don’t have to go duck hunting together, but next time you talk to someone belonging to a different tribe, maybe just introduce yourself and ask how they’re going.
If you would like to know more about this fascinating topic: In the video below Dr Brazil, who is also a gifted speaker, addresses a room full of medical tribes (but with a common interest in emergency medicine). She explains how we can overcome the dark side of medical tribalism. Enjoy.
Some time ago I was at a meeting with a great team of doctors and managers. We wanted to solve a particular difficult problem. The issue was discussed at length and we decided to invest time and money to improve the situation. Months later our group’s solution turned out to be a failure. We looked at each other in disbelief and asked: Why didn’t we see this coming? Did we really make this poor decision?
There are many advantages to working in a group or team, but there are also risks. When we’re in a group we often tend to avoid conflict and follow the leading opinion. This ‘groupthink’ phenomenon has lead to many historic disasters such as the explosion of the Space Shuttle Challenger and even the Vietnam War. Groupthink stops critical thinking and may lead to an unhealthy decision-making process. It can happen everywhere, including social networks such as Facebook and Twitter where group loyalty or group pressure may prevent airing of alternative ideas.
Last week I was watching World War Z. In this movie Brad Pitt fights the latest pandemic: a zombie apocalypse. Ten days before the pandemic is in full swing an intelligence report mentions the emergence of zombies. “Zombies? You’ve got to be kidding me,” was the response. The report was dismissed. Except… in Israel, where the intelligence service followed the ‘tenth man rule’: when nine people agree, one person – the tenth – has to prove them wrong. In the movie this person convinced the Israeli intelligence service to prepare for a zombie war – and Brad Pitt of course finds a way to save the world.
I’m not sure if the tenth man rule is real or not, but in World War Z Israel implemented this decision-making model because the Jews had been caught out too many times in history, for example during the Second World War and the Yom Kippur war. The signs on the wall were ignored by decision makers, and Israel was determined not to let this happen again. Read more in this excellent post: What World War Z Can Teach You About Critical Thinking.
There are many other ways to make better group decisions, such as looking at the risks of each decision or wearing different thinking hats. A good chair encourages critical thinking. Researchers have suggested ways to avoid groupthink. Here are 8 useful tips from psychologist Irvin Janis (borrowed from this article):
Leaders should assign each member the role of ‘critical evaluator’. This allows each member to freely air objections and doubts.
Leaders should not express an opinion when assigning a task to a group.
Leaders should absent themselves from many of the group meetings to avoid excessively influencing the outcome.
The organisation should set up several independent groups, working on the same problem.
All effective alternatives should be examined.
Each member should discuss the group’s ideas with trusted people outside of the group.
The group should invite outside experts into meetings. Group members should be allowed to discuss with and question the outside experts.
At least one group member should be assigned the role of Devil’s advocate. This should be a different person for each meeting.
Teamwork is essential in healthcare. Yet, too often, we act as individuals looking after our own interests. Solving problems together, even if the objectives seem opposed, is beneficial for all parties for many reasons.
Stephen Covey introduced the principle of win-win in his book the Seven habits of highly effective people. It’s still a great principle for conflict resolution, incl in teams, groups, organisations etc. Covey:
Win-win sees life as a cooperative arena, not a competitive one. Win-win is a frame of mind and heart that constantly seeks mutual benefit in all human interactions. Win-win means agreements or solutions are mutually beneficial and satisfying. We both get to eat the pie, and it tastes pretty darn good!
A win-loose outcome is bad for all parties. Even though the winner may feel triumphant, the loser may not want to deal with the winner ever again.
So what’s required for a win-win result? First of all it requires an open mind. Black & white or good & bad thinking is not helpful and often not realistic either. Secondly, understanding the other party is crucial: Where do they stand? What is important for them? Where is the common ground? And finally: flexibility, as there are always more solutions to a problem.
Win-win is not about being nice, as Covey said. It’s about being courageous and considerate at the same time.