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?
“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
“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.”
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