Happy Interdependence Day

If someone said to me that I could only read one person for the next ten years, Atul Gawande would be among my finalists.

His May 26, 2011 New Yorker essay, Cowboys and Pit Crews, is the transcript of his recent commencement address at Harvard’s Medical School. As always, it’s insightful and important.

Here’s an excerpt:

     The core structure of medicine—how health care is organized and practiced—
emerged in an era when doctors could hold all the key information patients needed in
their heads and manage everything required themselves. One needed only an ethic of hard
work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop,
loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a
few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the
cultures, administer the antiserum. The nature of the knowledge lent itself to prizing
autonomy, independence, and self-sufficiency among our highest values, and to
designing medicine accordingly. But you can’t hold all the information in your head any
longer, and you can’t master all the skills. No one person can work up a patient’s back
pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the
treatment of the unexpected cancer found growing in the spine. I don’t even know what it
means to “protocol” the MRI.

     Before Elias Zerhouni became director of the National Institutes of Health, he was
a senior hospital leader at Johns Hopkins, and he calculated how many clinical staff were
involved in the care of their typical hospital patient—how many doctors, nurses, and so
on. In 1970, he found, it was 2.5 full time equivalents. By the end of the 1990s, it was
more than fifteen. The number must be even larger today. Everyone has just a piece of
patient care. We’re all specialists now—even primary care doctors. A structure that 
prioritizes the independence of all those specialists will have enormous difficulty
achieving great care.

The problem according to Gawande is “We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.

In my field, teacher education, we train, hire, and pay teachers to be cowboys. But students need pit crews. Increasingly, the world of work require employees to function as team members.

Older docs, Gawande points out, don’t like the changes because they miss their autonomy, independence, and self-sufficiency.

Just like those older docs, I dislike the forced teaming that’s increasingly required of me. For pit crews to work, Gawande argues, “you must cultivate certain skills which are uncommon in practice and not often taught.”

The problem at my workplace is everyone else dislikes the forced teaming at least as much as me. And we’re lacking the skills Gawande alludes to. Given that increasing interdependence is a reality, it behooves us to first identify and then cultivate the “certain skills which are uncommon in practice“. To do that, we can either wait, probably for a really long time, for formal leadership to take the initiative, or we can, as I propose, take the bull by the horns ourselves.

First, a trusting, caring work culture must be created where all the team members are willing to talk openly and honestly about whatever misgivings they have about proposed group projects. Too often some of my colleagues choose not to participate in planning meetings, and then, as soon as the meeting is over, vent to one or two people about the direction of the conversation in the privacy of their offices. The technical term for this is passive-aggressive bullshit.

Another fundamental problem is people commit well in advance to being at certain places at certain times to help the team out in specific ways, only to say they can’t make it once the date draws near. Sometimes they work with the team to reschedule, other times they don’t. When a few people aren’t dependable and don’t pull their weight, conscientious team members become bitter about having to do more than their fair share of the work.

Bitterness builds, trust is eroded, teamwork suffers, and people’s negative associations with teaming harden.

Then the question is whether we should press pause and revisit people’s past frustrations in an effort to get to the bottom of why some people are resentful. Like a troubled couple that refuses to enlist the help of a counselor, the answer is always no, “If we just do the work, people’s frustrations will subside.” But they don’t, instead, they build.

Until trusting, caring communication becomes a group norm, my three team essentials—1) actively participate in team planning; 2) show up when you say you’re going to and do what you’ve committed to; and 3) at least try to have a sense of humor—won’t make a bit of difference.

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