Teamwork training in medical school should be more rigorous

I’ve had a couple of sour experiences with teamwork since entering medical school.  These experiences are bad teamwork of the usual sort: a miscommunication, a slighted ego, and pretty soon we’re starting arguments with no other reason than to prevent the other person from having his way.  And though I know experiences of bad teamwork are common place in any work environment, watching Atul Gawande’s TED talk impressed me with the high stakes of bad teamwork in health care and the sad truth that the cost of this kind of petty dissent is borne by patients rather than the poorly performing team.

In his talk, Gawande argues that the staggeringly complex modern form of medicine today must be addressed by better teamwork and not just more medical knowledge, simply because it is beyond the capacity of any one person to know it all.  We must train to work together as “pit crews” instead of as “cowboys” if we are to contain costs, avoid medical errors and ultimately improve patient care.  Yet this sort of training is not done well in medical schools.   Without deliberate intervention, traditional medical school is generally a learning environment that not only suffers from an absence of effective teamwork training, but implicitly discourages teamwork by failing to recognize it as a learnable skill.

Traditional medical school is stereotypically painted as a learning environment filled with hours of didactic teaching, rote memorization and fact-based testing.  And in spite of efforts by the Royal College of Physicians and Surgeons in Canada to promote more diverse physician competencies via the CanMEDS roles framework (communicator, collaborator, manager, health advocate, scholar and professional), my experience so far has been that medical school delivers on its stereotype.  We might learn that communication and collaboration are important, but there is no curriculum for teamwork, no standard for excellence, and no encouragement for students to improve.  The interpersonal physician competencies become platitudes; they’re good qualities to have but that’s all you ever hear about them.  I believe students respond by adopting attitudes ranging from laissez-faire to cynicism: “how you communicate is just a matter of personal preference”, “we’ve beaten this topic to death”, “there’s no point in being a good communicator since we’re not graded for it”.

But teamwork is trainable.  Not only that, better teamwork is correlated with improved patient safety.  So why is there such little class time devoted to teamwork and why is the curriculum so underdeveloped?  We get full lectures on the clinical findings, abnormal lab tests, pathogenesis and treatment options for diseases like dermatomyositis, which has an incidence of around 1 in 100 000.  To put that in perspective, in 2004 preventable adverse events (ie. medical errors) affected about 200 out of every 100 000 Canadians.  How do these preventable adverse events happen?  Well, someone lower in the medical hierarchy might notice an issue in patient safety but be disregarded by his or her superior.  Better teamwork, though, through explicit lessons on listening to all team members (among other things), can reduce mortality in the surgical setting from 18% to 7%, and improve quality of care, reduce post-operative pain, improve post-operative function and decrease length of hospital stay.

Given these benefits, it would seem wise for schools to train good teamwork early in medical school.  Schools have made some progress to facilitate teamwork, with many moving to a pass-fail system to reduce competition between classmates.  But more could still be done to improve the teamwork training in the first two years of undergraduate medical education in preparation for clerkship, when students properly enter the work environment of hospitals for the first time.

First, teamwork training should use projects that require cooperation to complete.  There are too many “team” projects in medical school that can frankly be completed by one hardworking individual and usually that’s how they’re completed.  Contrast that with a project at the University of Washington that brings together students from pharmacy, nursing and medicine to work on cases where each team member receives different information about the patient.  Not only does this mimic a real life scenario in the representation from different professions, but it also encourages teamwork because there are differentiated roles with complementary function–no one is redundant, and you need the other person’s information to formulate a management plan.

Second, there should also be follow up with debriefing of what worked and what didn’t, and include lessons from the leading edge of team research on what could be done better.  This would give students opportunities to practice communicating constructive criticism as well as the chance to improve how they work with others between projects.  Too often, medical students resort to talking behind the backs of students when there is a conflict, and it would be easier to learn how to address team conflict if a forum for this were initially opened by the higher authority of the school.  Hopefully, then, students will learn how to do this on their own initiative.

The responsibility of medical school is to take novice students and graduate them as competent doctors, and schools have long been ready to tackle the challenge of teaching students medical information.  It’s time for schools to teach teamwork as well.  That way, medical students who come in as bad team players can graduate as skilled team players, and patients don’t need to worry that some little argument could cost them their life.