Feb 6, 2009

Practicing Like A Rock Star: The Need for a Culture Change in Medicine

Consider this definition:

prima donna: (noun) 1. a first or principal female singer of an opera company. 2. a temperamental person; a person who takes adulation and privileged treatment as a right and reacts with petulance to criticism or inconvenience.

We've all interacted with these types of people before. They hog the basketball on the courts and refuse to pass the ball. They must be placed front and center in every dance formation if not given a solo. They are the rock stars that never show up for rehearsals, claim all of the glory, and blame others when their voice is shot from partying all night long. In several industries such as sports, dance, opera, aviation, and medicine these rock stars usually have amazing talent and have worked hard to reach their top position. But, what they fail to recognize is that their trade goes beyond their individual bubble--it's a team effort.

Dance and performance have been very important parts of my life from as early as I can remember. How many hours have I spent in rehearsal? How many people have I performed before? Those questions are just impossible to answer. Throughout college, I was involved with a dance troupe called the Asian American Dance Troupe. Every spring we would host a dance show on campus highlighting a wide range of Asian dance styles. The show, Eastbound, was always a huge, almost all-consuming, undertaking not only because of the 40 plus dancers in the troupe, but also because of the tremendous amount of coordination that was required to deliver a successful show.

Just to give you a flavor of what goes through the minds of the troupe's captains and board:

  • Show shouldn't be more than 1.5 hours long. Absolute max 2 hours. Don't want people to be bored
  • 14-16 pieces
  • Need entertaining MCs
  • Adequate spacing between pieces to allow for quick changes. Enough spacing for pieces with very complicated costumes
  • Coordinate and space dancers in multiple pieces. Avoid back-to-back pieces and if unavoidable, veterans can better cope than newbies. Make sure we have enough guest groups to fill in between pieces
  • Need stage managers and runners who are authoritative, are familiar with pieces, and know almost everyone's names
  • Each dance needs costumes with strong stage presence. Coordinate costumes with choreographers and okay with costume manager
  • All dances must be ready! Ask choreographers to be responsible for own dancers
  • Block off lots of studio hours for last minute rehearsals
  • Each dance needs proper lighting cues that match costumes and mood of pieces well. Coordinate with lighting director
  • Lighting director and sound manager need to attend formal training sessions with performance space manager
  • Ask sound manager to compile all music for show together on one CD, including guest group music
  • Water and snacks in dressing rooms to keep dancers hydrated and happy
  • Separate rooms for boys and girls, make sure not too many dancers in one room
  • Need at least three cameras for filming. Hopefully, they are of comparable quality. Volunteer camera crew?
  • Coordinate selling of bubble tea refreshments during intermission
  • Coordinate police detail
  • Cash box! Tickets! Lowell Lecture Hall seats 300 people!
  • Tape the performance space. Mark center center, center front, center back
  • All costumes need to be ironed

And that's just a subset of what feels like a million processes that must be executed for a successful show. How many people did I mention? 40+ dancers, a costume manager, a lighting director, a sound manager, performance hall manager, choreographers, guest groups, stage manager, film crew, audience members, and the list continues. A successful Eastbound requires full participation from all of these individuals--the performance team, and interactive communication among all. When something goes wrong, in the spirit of "the show must go on", the performance team steps up and takes care of the situation quickly and appropriately. As the audience claps at the end of the show, we all take the stage as a team and celebrate. WE did it!

I've performed with several different groups and must confess that a culture of teamwork is often the exception and not the norm. If we all don't pitch in to iron all of the costumes or go over the last eight counts of the first piece to make sure the circle formation does look like a circle, the audience's experience is diminished and our reputation is damaged. Everyone is a star dancer, but to truly make an memorable impression we need to be a stellar troupe.

Similarly, in health care, a patient's care does not lie heavily on the shoulders of one individual. A performance team of physicians, nurses, pharmacists, technicians, surgeons, administrators, receptionists, and many others all are part of the patient's experience. If Team Member A forgets to sterilize an instrument, Team Member B should speak up, and Team Member C can help find one that has been sterilized. Everyone on the performance team is a hero to the patient because they are providing them with much needed help--the performance team can save lives!

On January 15th, Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, wrote in his blog, "Running a Hospital" about the resounding evidence of the use of a checklist to prevent surgical complications and what it takes to implement change in the health care system. Immediately following his provocative post is an even more thought-provoking dialogue bringing together patients, practicing physicians, nurses, and other care givers with some of the greatest leaders in the field studying the implementation and spread of best practices.

Are physicians prima donnas? Perhaps they are. But are they really to blame? Perhaps they are just a product of the current medical culture. A culture as Dr. Berwick shares in a comment that trains physicians to believe "a self-image of heroism, autonomy, and artistry...that the patient's fate is in their hands - that they personally and individually are responsible for excellence...They are not being dumb. They are pursuing the form of excellence and responsibility that they have been told to pursue."

In the dance world we excuse a prima donna attitude because of his/her talent. But, to achieve a fantastic show we need to stop making excuses. When we know that patient care could be better we need to stop allowing care givers to operate as lone individuals. The depth and breadth of skill necessary now to provide the best care to patients is too deep, too complex, and too wide to be a lone hero. As Gary Kaplan, CEO of Virginia Mason Medical Center said, "Our training to only trust ourselves to ensure our patient's well being is deeply rooted but ultimately maladaptive for today's complexities in diagnosis and treatment."

So what can we do to promote team work? As health professions students, I think we could start with better understanding of our patients and teammates. Spend a day with a patient and see how he/she sees the system. Spend a day with a nurse, spend a day with a physician, spend a day in the lab, spend a day with an administrator...and most importantly discuss your experiences with others. Any other ideas of how we can usher in a new culture of teamwork into health care?

I'll admit that I used to think that the tech crew helping with our shows were insensitive and incompetent. Didn't they know that red lighting flooded and overpowered pink costumes? Couldn't they hear the music and energy shift? That was until I went up to the tech pod and saw the large and complex switchboard that controlled all stage lights. Creating purple light didn't just require one button, but a pull here and a flick of this and a push on that. It was my impatience and lack of understanding that led to my frustrations with the tech crew. They were doing their best. After explaining what we wanted in advance and respecting their own artistic touches and expertise, I've never had difficulties with lighting. Since then, I've come to appreciate how lighting helps to set the tone of a piece and enhances our ability to express ourselves.

So, I guess the key to practicing like a rock star is to simply not practice like a rock star. Embrace the team and you'll see that practicing within a rock band is even cooler. If anything, you will always have your band mates with you to get through the bad and celebrate the good.

Click here to read an article in The New York Times titled "Arrogant, Abusive and Disruptive--and a Doctor" to see how teamwork breaks down.

Want to get into a great residency program?

If you're reading this, you probably think improving the quality of health care is pretty important. Here's someone who agrees with you:

Joel Katz is Assistant Professor of Medicine at Harvard Medical School and director of the Medicine Residency at Brigham & Women's Hospital -- one of the finest hospitals in the U.S.

When he's selecting residents, Dr. Katz looks for students who are interested in improving the quality of health care. In his own words:

The principal mission of the residency is to train great doctors -- "great" meaning doctors who can recognize who is and is not sick, act decisively in the absence of a complete data set, think critically about the 'big picture' of health and disease, and know their limits and feel comfortable seeking the advice and wisdom of their peers.

At the Brigham, Dr. Katz has recently launched a residency track in management leadership skills, including those directly relevant to patient safety and quality improvement.

Dr. Katz will be checking this blog between now and February 24. Leave a comment or a question for him here, and he'll see it. Ask anything you want. Curious about why most professional training programs don't emphasize the improvement of care? Want to know how you can make patients safer? Hoping for some tips on how to stand out in your field?

To ask a question, click the "Comments" link at the bottom of this post.