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Leadership for Complex Care: The Ship’s Ballast in Troubled Waters

Blog Post · August 7, 2017

We recently spent two hours with a group of clinicians trying to understand the complex experience around who oversees care. There was no consensus: the surgeon, intensivist, and cardiologist all proclaimed themselves to be captain of the ship. The cardiologist argued that he refers the patient to the surgeon for care, so therefore the patient is “his.” The surgeon said that, because he shepherds the patient through the most complex and consequential aspect of care, the patient was his. And the intensivist maintained that since neither specialist was continuously present in the critical care unit when the patient was most in need of minute-to-minute care, the patient was hers.

Various care models and metaphors were proposed. The surgeon suggested that there was a pilot and co-pilot. Though all three clinicians agreed with this model, they couldn’t decide on who held the respective “co” position because they each saw themselves as sitting in the pilot’s seat. Ballroom dancing was proposed, but this failed consensus because someone “leads.” In another construct, one specialty owned the car, and the other was allowed to drive it; predictably, there was no agreement on whose name was on the car title.

As clinical leaders who have developed teams in different organizations to navigate complex care environments, we have long maintained that the traditional focus on who captains the ship is misguided. In many complex clinical scenarios, there is often no single right way to do things. Having many different physicians bring their attention to a difficult problem can minimize the chance that something will be missed. Specialists tend to see care from their particular perspectives and, in the absence of collaboration, may not fully appreciate the effects of a therapeutic intervention in areas where they do not usually focus.

Leadership for Complex Care: Interdisciplinary Team for a Patient on Extracorporeal Life Support

  Click To Enlarge.

It is understandable that any physician who is forced to choose between being surprised by what has happened to a patient and micromanaging the process of care will choose to micromanage. As the medical sociologist Renée Fox has pointed out, physicians struggle with uncertainty. To respond to this challenge, we have worked with our clinical teams to ingrain a culture of intensive communication to help avoid the surprises that no one likes.

To start with, we have allocated time to forums in which interdisciplinary teams expect to interact with each other and create a shared plan. At Cedars-Sinai, senior hospital leadership regularly “drop-in” on these forums, demonstrating institutional commitment to interdisciplinary care. In addition, we have created expectations that when deviations from an agreed upon plan are necessary — as they often are with rapidly evolving clinical scenarios —those involved in care will be updated. Finally, standardization of care with clinical pathways and guidelines greatly helps in creating common expectations, and can be applicable to a large proportion of high acuity patients.

For some physicians, the dictum to communicate frequently and comprehensively presents a challenge beyond the fact that it adds time to an already busy day. Because medical training is designed to foster progressive independence, the advice to talk repeatedly to a colleague may feel like it conflicts with hard-won independence and mastery of practice. The trick is to understand that intensive communication is needed, not because anyone’s skills or judgment is in question, but because a fellow specialist is equally invested in the patient and does not want to be surprised.

Good communication requires both a push and pull: stating one’s opinion, and at the same time, being open to others’ views. Skilled clinicians create the conditions that make their colleagues feel valued and good about themselves — the fertile soil needed for collaboration. This work starts with the humility to accept, on occasion, someone else’s care plan that is different from one’s own. Contrast this approach with the physician who becomes surly and more insistent when his perspective is challenged, which in turn hardens others’ willingness to accept an alternative point of view.

When surprises are too frequent, many physicians will reflexively micromanage care. This presents an affront to the other clinicians involved, who treasure their independence and competence. It also can create a situation where collaborating caregivers stop thinking about how best to conduct care and instead wait for instructions. If someone is going to change the care plan, why bother to make one? This tendency to micromanage is often accompanied by other dysfunctional behaviors including aggressive or intimidating conduct toward other caregivers that creates an unhealthy working environment by impeding a team’s willingness to communicate freely.

Novice clinicians sometimes look at the need to communicate intensively as a rite of passage — something that must be done until their colleagues gain confidence in their abilities. This thinking is misguided. The issue, again, is not that one is communicating because of a concern about competence, but because counterparts are equally invested in care. Indeed, the most experienced and skilled physicians often communicate about seemingly minor issues more frequently and adeptly than their more junior colleagues. Sharing small nuances and occurrences empowers all physicians to speak knowledgeably and consistently when they interact with families and referring doctors.

Another common related pitfall is management of time. If one is hurried or has too many competing responsibilities, it becomes hard to communicate in a focused, effective manner. Communication around patient care is not simply a box to be checked on a to-do list; it is an activity that must be cultivated and requires time to be done well. In short, novices often do not devote adequate time to communication.

Cultivating communication skills takes investment, repetition, and mentorship. Indeed, it is the third, and equally important, element of a clinical triad that includes technical skills and judgment. While many young physicians see their careers as a journey to becoming captain of the ship, we believe that clinicians and leaders need to instead focus on working together to become the ship’s ballast: that which keeps the vessel upright in troubled waters.

 

This blog post originally appeared in NEJM Catalyst on July 20, 2017.


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