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Team Functioning IV:Teams in ActionKyle P. Edmonds, MD

Assistant Clinical ProfessorHowell Palliative Care ServiceUC San Diego Health

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• Vision: Graduating thoroughly self-aware team members.

• Mission: Increasing the self-awareness of HPM fellows over the course of their fellowship.

• Values: • Significant.• Applicable.• Personalized.

Mission, Vision & Values for the Thread

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• #1: Team Roles with me (Homework: Communication Style Inventory)

• #2: Communication styles with Dr. Ajayi (Homework: Parker Team Player Survey)

• #3: Teams in Action with me (Homework: Intercultural Conflict Style Inventory)

• #4: Managing conflict with Chris Onderdonk, LCSW (Homework: RHETI)

• #5: The Role of Personality Type with Kathryn Thornberry, LCSW (Homework: Develop Professional Mission/Vision/Values Statement)

• #6: Personal Team Style with Dr. Ajayi

The Arc of the Team Functioning Thread

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It’s day one on your new job…

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• History

• Intersectionality

• Norms

• Individual characteristics

• Environmental factors

• Leadership style

Factors in Team Functioning

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Absence of trust Fear of conflict Lack of commitment

Avoidance of accountability

Inattention to team needs

Wanting team results w / o

team structure

Underestimating process &

relationship

Culture discouraging to

collaboration

Impairments to team functioning

CAPC, 2012.

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Black-box warnings of potential team distress• One or more team members who are: disruptive, frequently absent, apathetic,

dispassionate, sarcastic, hopeless, and/or who express constant emotional/physical exhaustion, report frequent illnesses, or exhibit signs of palliative care “martyrdom”

• Chronic poor attendance at team meetings

• Chronic poor follow-through on assigned tasks

• Team member(s) repeatedly staying beyond normal work hours

• Intra-team conflicts or differences that are consistently unresolved

• “Junior high school” behaviors

• Frequent high clinical workload that precludes nonclinical activities

CAPC, 2012.

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If your team work is not the hardest and best way you’ve ever worked, you’re not doing it

right.

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Physician Family System

McKegney, 1989.

• unskilled at admitting needs / mistakesUnrealistic expectations

• admitting to pain, depression, uncertainty or abandonment is disloyalDenial

• loyalty more important than collaboration, can’t trust others

• hiding mistakes, perfectionism

Indirect Communication

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• deny feeling uncertainty or needing guidanceRigidity

• avoid interaction with other disciplines• distrusting of other’s values• Poor collaborative problem-solving skills

Isolation

• guiding / supervising is discounted• physician “grows out” of being “dependent”Indirect power of day-

to-day companions

Physician Family System

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What’s the hardest thing to do or talk about in your family of origin?

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Clash of the Hidden Curriculum

Physician hidden curriculumDoctors must be perfect.

Outcome is more important than process.

Hierarchy is necessary.

Uncertainty and complexity are to be avoided.

Medicine takes priority over everything else.

Adapted from Table 1: Browning et al., 2007.

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Clash of the Hidden Curriculum

Physicians Palliative teamPerfection Members must be comfortable with their own

imperfection & vulnerability.Outcome Attention to process can be critical to the achievement

of successful outcomes.Hierarchy Hierarchy can hinder optimal learning across

disciplinary lines.Ambiguity Uncertainty, ambiguity and complexity are to be

expected.Medicine Medicine finds its appropriate niche through optimal

collaboration

Adapted from Table 1: Browning et al., 2007.

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• Doctors in palliative teams must be…• …perfect, but imperfect and vulnerable.• …ignorant of and attentive to process.• …at the top of a pyramid that can’t

exist.• …avoidant of unavoidable uncertainty

and complexity. • …able to medicalize everything except

the stuff that shouldn’t be.

Clash of the Hidden Curriculum

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• Difficulty relaxing

• Presenteeism

• Work-life balance disruption

• Sphere of worry larger than sphere of influence

• Chronic feeling of “not doing enough”

• Difficulty setting limits

• Confuse self-interest with selfishness

Physician (Palliative Team?) Compulsiveness

Doubt

GuiltExaggerated

sense of responsibility

Gabbard, 1985.

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Sphere of Worry

Sphere of Influence

The Most Important Venn Diagram You’ll Ever See

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Sphere of Influence

Sphere of Worry

The Most Important Venn Diagram You’ll Ever See

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Leading Away from the Hidden Curriculum

Physicians A team approachPerfection Sufficient safety and trust to explore matters of personhood &

professional integrity.Outcome Attention to moral & relational dimensions of the work.

Hierarchy Explicit suspension of hierarchical structure & rules. “Nothing about us without us.”

Ambiguity Inviting reflection, self-awareness and tolerance.

Medicine Structured space for knowledge and insights from all disciplines.

Adapted from Table 1: Browning et al., 2007.

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A Shared Leadership Model: Trans-Disciplinary Teams

• Commonly treated as a peer• High knowledge deficit• Highly dependent on the other

members

Appointed leader

• Features of the situation• Individual skills & expertise• Individual ability to influence

Actual situational leadership

Pearce et al., 2009.

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Pharmacist

Clinical Social Worker

Nurse PractionerPhysician

Others

Shared Leadership: Situational

Appropriate for:Administrative decisions?

Local team decisions?Clinical decisions?

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• Words matter• Are you “ON” or “IN” a palliative

team?• “Call MY social worker”• “MY” or “OUR” team

Final Note on Language

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Team Functioning IV:Teams in ActionKyle P. Edmonds, MD

Assistant Clinical ProfessorHowell Palliative Care ServiceUC San Diego Health

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• Browning DM, Meyer EC, Truog RD & MZ Solomon (2007). Difficult conversations in health care: Cultivating relational learning to address the hidden curriculum. Doi: 10.1097/ACM.0b013e31812f77b9

• CAPC (2012). Strategies for maximizing the health/function of palliative care teams.

• Chaudry et al. (2007). Physician leadership: The competencies of change. doi: 10.1016/j.jsurg.2007.11.014

• Gabbard GO (1985). The role of compulsiveness in the normal physician. Doi: 10.1001/jama/1985.03360200078031

• Haidet P & HF Stein (2006). The role of the student-teacher relationship in the formation of physicians: The hidden curriculum as process. doi: 10.111/j.1525-1497.2006.00304.x

• McKegney, CP (1989). Medical education: A neglectful and abusive family system. PMID: 2612802

• Pearce CL, Manz, CC & HP Sims (2009). Is shared leadership the key to team success? doi: 10.1016/j.orgdyn.2009.04.008

• Serio & Epperly (2006). Physician leadership: A new model for a new generation. PMID: 16512590

References