Rethinking Cancer

I was blown away by the scope, clarity, interdisciplinary artistry, and intelligence of Siddhartha Mukerjee’s 2010 book, “The Emperor of All Maladies: A Biography of Cancer“. Like Atul Gawande, Mukerjee somehow practices medicine, runs a world class research lab, while being married with two school-aged children. I like this quote from his wife, Sarah Sze, a MacArthur Genius grant recipient and tenured art professor/sculptor at Columbia.

“‘You can’t get lost in the everyday details. Sid and I are both totally like that, which can be not good with things like parking tickets. Sure, things are falling through the cracks all the time, but that doesn’t matter. The big things matter.'”

I haven’t read Mukerjee’s 2016 book, “The Gene: An Intimate History,” but did just finish his recent New Yorker essay, “The Invasion Equation,” about how cancer biologists are rethinking cancer. And he’s done it again, written so clearly even I can make sense of the science. His writing is deeply engaging on top and will not disappoint anyone interested in the current state of oncology.

A one-sentence caption on the second page of the essay summarizes the shift in thinking:

“We’ve tended to focus on the cancer, but its host tissue—”soil,” rather than “seed”—could help us predict the danger it poses.”

Later, he elaborates:

“It was only natural that many cancer biologists, confronting the sheer complexity of the whole organism, trained their attention exclusively on our “pathogen”: the cancer cell. Investigating metastasis seems more straightforward than investigating non-metastasis; clinically speaking, it’s tough to study those who haven’t fallen ill. And we physicians have been drawn to the toggle-switch model of disease and health: the biopsy was positive; the blood test was negative; the scans find “no evidence of disease.” Good germs, bad germs. Ecologists, meanwhile, talk about webs of nutrition, predation, climate, topography, all subject to complex feedback loops, all context-dependent. To them, invasion is an equation, even a set of simultaneous equations.”

My take-away from Mukherjee—whether you or I are likely to die from cancer depends largely on whether oncologists learn to think like ecologists.

Every Team is Better and Worse Off Because You’re On It

Atul Gawande, one of my favorite authors, is about to gain a wider audience through this new book that will do very well.

His New Yorker essay, Cowboys and Pit Crews, got me thinking about how we live our lives on a never ending series of teams whether grade school classrooms, athletic teams, art and music based teams, community groups, home owners associations, church councils, families, school faculties, work teams, book clubs, special interest groups, political campaigns, boards of directors, etc.

You would never guess that if your only frame of reference was elementary, secondary, and higher education classrooms in the United States. Students almost always work on things individually and faculty almost always assess students individually. Sure, sometimes students work in small groups, but they’re not taught to be thoughtful observers of small group dynamics. It’s rare that they’re ever asked why some small groups work well and others don’t. Too often, teachers wrongly assume students already know how to be good teammates. As a result, students tend to be clueless about group dynamics.

And since teamwork doesn’t factor into student evaluations, they’re even less self aware of their team-based strengths and weaknesses. They’re hardly ever asked the most basic group process related questions such as, “What do you do well as a team member? What’s most challenging for you when working closely with others? Where could you improve?”

Every person, you included, has specific skills, knowledge, and personal attributes that benefit and hamper all of the teams they are on at any one time. Which of your skills, knowledge, and personal attributes do your team’s often use to positive advantage? And how does your presence on teams sometimes limit their effectiveness? What could you do better as a teammate?

Aren’t sure how to answer those questions? Welcome to the “Almost Everybody” Club. It’s not your fault. Individualism is so pervasive in American life, schools think about students as cowboys  and cowgirls despite the fact they’ll live their lives on pit crew after pit crew.

 

Teaching Teamwork

In May, 2011, Atul Gawande gave an insightful commencement address to Harvard’s Medical School graduates.

He reminded the graduates that the practice of medicine had changed markedly, and that increasingly, the best docs are members of teams.

Gawande pointed out that, “The doctors of former generations lament what medicine has become.”

I’m having my graduate-level teacher certification students read the address. On the copy I’m providing them, I’ve lined out “doctors” and “medicine” and written in “teachers” and “education”.

Here’s Gawande’s primary point:

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.

Today, isn’t it a workplace truism for nearly everyone that “. . . you can’t hold all the information in your head. . . and you can’t master all the skills”?

Gawande adds:

The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.

On my students’ copies, I’ve lined out “doctors” and “people” and substituted “teachers” and “students”.

Gawande acknowledges that medical education fails to teach docs to function like pit crews for patients. The same is true for teacher education.

Too often nursing, medical school, and teacher education faculty wrongly assume that novice nurses, docs, and teachers will naturally, through osmosis, form knowledgeable, skilled, interdependent work teams. Absent intentional team-building curricula, in which case studies would be an integral component, professional apprentices depend upon the modeling of their veteran colleagues, often out-of-step ones pining for old school independence and autonomy.

When in comes to intentionally teaching teamwork, what can and should professional preparation programs do to shift the balance from cowboys to pitcrews? More generally, what can employers do to teach teamwork?

They shouldn’t assume it’s something someone is either born with or not. Effective teamwork can be taught through case studies that illuminate what the best teams do and what commonly trips up most others. And by proactively providing pre-professional students positive examples of excellent teams during their fieldwork.

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.