Roger's Textbook of Pediatric Intensive Care - Chapter 4

Roger's Textbook of Pediatric Intensive Care



Chapter 4
Professionalism, Simulation Training, and Leadership in Pediatric Critical Care
Alice D. Ackerman
Elizabeth Hunt
Vinay Nadkarni
 
 
The goals of this chapter are to elucidate some of the important concepts of professionalism and leadership as they apply to the everyday lives of pediatric intensive care practitioners and to emphasize how utilizing these concepts can make the practice of pediatric intensive care more effective, more efficient, more patient centered, and more rewarding. The focus is on aspects of professionalism and leadership as they pertain mostly to the physician and relies upon literature primarily from North American and European sources, which in no way is intended to exclude other intensive care professionals or suggest that the primarily Western views described are the only valid concepts guiding our behavior. Because the notion of “professionalism” has become enmeshed within our training programs with how we teach our trainees, much of this chapter also focuses on the educational approach to both professionalism and leadership. Material presented in this chapter, when understood in the context of the other chapters in this section, helps to complete the discussion of the “core competencies” beyond the cognitive knowledge base required of our practitioners.
Professionalism
Historical Background
Origins of Professionalism
The Western understanding of the medical professional originated with Hippocrates in the 4th century, BCE. The oath that bears his name is a very personal commitment to use one's ability for the good of patients. It gives honor to the teachers and mentors of the medical profession. It specifically prohibits the physician from performing euthanasia. It speaks to the morals of the physician, in connection with her medical practice and with everyday life. It requires the physician to maintain patient confidentiality and allows the physician to garner the respect of society as long as she upholds the oath. It has guided our expectations of physician ethical and moral behavior for over 2000 years. Most medical students in the US recite this or a similar oath at their graduation, prior to receiving their degrees. If all physicians continued to live and practice in line with the simple requirements of this oath, chapters such as this would not be included in such textbooks. However, the growing number of committees established to manage “code of professional conduct” issues in medical schools and hospitals attests to the unavoidable fact that physicians, among other healthcare professionals, do not always uphold the most basic of rules. In addition, our understanding and expectation of professionalism has changed over the past centuries.
Professionalism in the 20th Century
Starting in the mid-1900s, the definition of a profession assumed the more societal reflection that it maintains today, compared to the individual focus predominant in the 19th and early 20th centuries. Modern society expects and demands that members of a profession be formally trained to gain a specific knowledge base. It allows the profession to be largely self-regulating with regard to standards of education, performance, and disciplinary mechanisms. A member of the profession is expected to be more oriented toward public service than to individual profit and to behave according to a code of ethics. In exchange, society accords members of the profession a relatively high stature and respect.
More recently, changes in society and within medicine itself have led to concerns about the medical profession as a whole, as well as the behavior of individual members of the profession in particular. Skyrocketing healthcare costs, the impact of managed care limiting physician reimbursement and independence, and an ever-increasing technologic complexity have affected the internal and the external perceptions of what constitutes appropriate professional behavior.
Table 4.1 Commitments of the medical professional
Commitment Examples
Professional competence Engage in life-long learning; maintain necessary skills for self and team; ensure that all members of the profession remain competent
Honesty with patients Inform patients truthfully; acknowledge errors
Patient confidentiality This may not be possible if patient poses a risk to society.
Maintaining appropriate relationships with patients Includes the avoidance of sexual relationships, using patients for financial gain, etc.
Improve quality of care At both an individual and systems-wide level, participate in mechanisms that encourage continuous improvement in care delivery
Improve access to care Promote public health, preventive medicine, and patient advocacy; eliminate discrimination within physician's own system of practice
Ensure just distribution of resources Provide cost-effective care; use evidence-based guidelines
Further scientific knowledge Uphold scientific standards, promote research, create new knowledge; ensure its integrity
Manage conflicts of interest Full disclosure
Professional responsibilities Work collaboratively with others; discipline those who fail to uphold professional standards; develop new standards and train new members appropriately
Adapted from Medical Professionalism Project. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002; 136:243–246.
Professionalism Today
New standards of the Accreditation Council of Graduate Medical Education (ACGME) require that professionalism be taught to residents and fellows, and the new standards for maintenance of certification (MOC) of the American Board of Pediatrics (ABP) require evidence of ongoing professional behavior in its diplomates. Other requirements for MOC include excellence in patient care, evidence of practice-based learning and improvement, evaluation of interpersonal and communication skills, and demonstration of the understanding of the components of systems-based practice, in addition to satisfactory completion of the traditional standardized secure examination.
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As discussed next, the components of MOC revolve around a new definition of medical professionalism.
Professionalism and the “Core Competencies.”
In 2003, the Institute of Medicine (IOM) (11) declared that today's medical professional should be able to provide patient-centered care, work in interdisciplinary teams, employ evidence-based principles, apply quality-improvement methodologies, and utilize informatics in the practice of medicine. These are the five noncognitive “core competencies” that the physician of the new millennium is expected to possess. They were adopted by the ACGME in the form that is probably more familiar to both trainees and practicing intensivists: patient care, practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice (1). These competencies form the core but not the entirety of our professional behavior. Clearly, each identified competency includes a multitude of specific knowledge points and behavioral characteristics. How are the IOM's competencies related to professionalism?
Professionalism and the “Physician Charter.”
The relationship between the core competencies and medical professionalism was addressed in part by the American Board of Internal Medicine (ABIM) Foundation, working in conjunction with the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) Foundation and the European Federation of Internal Medicine in the 2002 publication, “Medical Professionalism in the New Millennium: A Physician Charter,” which appeared simultaneously in the Annals of Internal Medicine (24) and the Lancet. This publication was the outcome of a summit of numerous medical societies throughout the US and Europe, an attempt to call to action physicians throughout the world to develop a renewed sense of professionalism. The charter set forth 10 commitments (Table 4.1) of the professional once she has acknowledged the guiding ethical principles of the primacy of patient welfare, patient autonomy, and social justice. The items listed in the Physician Charter represent a potentially desired outcome; however, the roadmap for how to reach this proposed optimal state of the medical professional is not inherent in the charter.
In 2002, the Royal College of Paediatrics and Child Health (RCPCH) in the UK published a statement on the duties and responsibilities of pediatricians, entitled “Good Medical Practice in Paediatrics and Child Health.” This document defines the ways in which the “good-enough doctor” can be recognized and unacceptable behavior or performance can be identified. It focuses on many of the same areas as does the ABIM Foundation Charter, but it is specific to those who care for children, and it provides concrete examples of acceptable and unacceptable practice. The Royal College identifies actions and behaviors that could cause the pediatrician in the UK to lose his registration with the General Medical Council. The individual examples of unacceptable behavior are elucidating. Overall, the document lists 59 duties and responsibilities, divided into the following eight major areas: Good medical practice (professional competence); good clinical care (the practice of competent care, ensuring appropriate access to care); maintaining good medical practice (keeping abreast of current medical knowledge and maintaining performance); teaching and training, appraising and assessing; conducting relationships with patients (consent, confidentiality, trust, communication,
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and terminating physician-patient relationships); dealing with problems in professional practice (conduct and performance of colleagues, complaints, and malpractice insurance); working with colleagues (treating colleagues fairly, working in and leading teams, arranging cover, accepting appointments, sharing information, and delegation and referral); and finally, a section entitled “probity,” which deals with conflicts of interest, research, personal health, financial interests, and related issues. It also addresses the seeming paradox that arises when one is encouraged to participate as a member of an interdisciplinary team, yet professionalism demands that one take personal accountability for one's professional conduct and the care provided. Readers are encouraged to obtain this document, which is available at www.rcpch.ac.uk/publications/recent_publications/GMP.pdf (26).
The CoBaTrICE (Competency-based Training programme in Intensive Care Medicine for Europe) collaboration published a list of competencies expected of adult intensive care physicians based on consensus developed over a 3-year period. Professionalism is one of the 12 “domains” listed and was weighted heavily in importance by the majority of the participants in the Delphi processes (22) used to develop consensus. Within the professionalism domain, CoBaTrICE includes the following competencies: communication skills; professional relationships with patients, relatives, and other members of the healthcare team; and “self governance” (5).
Personal Attributes of the Medical Professional.
These descriptions of professionalism place a great deal of emphasis on the outward, measurable or observable conduct of the physician but pay little attention to the intrinsic attributes that identify a physician as a true professional. The American Association of Medical Colleges (AAMC) has determined that the medical professional in today's society should be knowledgeable, skillful, altruistic, and dutiful, and has encouraged schools of medicine to incorporate teaching of professional attitudes and behaviors into their curricula (15). Others add qualities such as compassion, integrity, fidelity, and self-effacement as important in the “good” doctor (7). Gregory Larkin, who writes about how to model and mentor students in professionalism, suggests that we first map virtues and vices in professional practice. He has identified “four valences” of professional behavior in order of best to worst: ideal, desired, unacceptable, and egregious (19). For example, ideal behaviors would include showing altruism toward others and having humility regarding one's own achievements. Desired behaviors would be acting in the best interest of the patient and arriving on time for work. On the negative side of the spectrum, unprofessional behaviors would include arriving late or breaching confidentiality, while egregious behaviors would include lying, falsifying medical records, and engaging in substance abuse.
Teaching Professionalism
Once we understand what actions, behaviors, and attributes are consistent with professionalism, the next question becomes: “How do we teach this?” The answer is both simple and complex. Although the most important aspect of learning to act as a professional appears to be having the appropriate role models (7,15), we nonetheless must find a way to help our students and trainees understand the relationship between such ideal attributes as altruism and the behaviors—good and bad—that they observe daily at patients' bedsides. Many schools of medicine have developed courses on professionalism or humanism, yet students today are graduating with a cynicism that they did not have 40 years ago. Why?
Dichotomy between Ideal Behavior and Reality.
Students learn in the clinical setting by observing the behavior of many individuals with whom they interact. It is not just the wise professor, who embodies all of the desired virtues of the physician, who will affect those most likely to be influenced. Rather, it appears that students are most influenced by those with whom they spend the most time. The influence of residents and fellows on the attitudes of medical students has probably been underestimated. Students and trainees not only hear what we say, but note what we do; in a significant number of cases, the two are diametrically opposed. We are, in fact, teaching cynicism (7,15). Critical care clinicians must find a way to stay centered on the core values of the medical profession as we care for patients and as we train our students and residents/fellows. Schools of medicine, while stating that they wish faculty to exhibit professional behavior and serve as role models for students, residents, and fellows, may not reward the outstanding clinician-teacher role model as well as or as overtly as they reward the successful researcher-academician (19). The gap between what we say we want and what we reward must be closed or at least diminished if medicine wishes to make professionalism a reality and to establish those physicians who embody professionalism as revered role models.
Impact of Burnout on Professional Behavior.
Trainees themselves often do not realize their impact on students or other trainees. A significant percentage of residents may suffer from burnout (a syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment), and this can easily be transmitted to the students and colleagues with whom they work. Burnout among internal medicine residents was associated with self-reported unprofessional behavior in a recent study (27). Critical care units are stressful places; black humor and occasional disdain for the patient have been noted to occur. Burnout is a major problem among residents, fellow, and attending physicians (4,21,25). The risk of unintentionally teaching unprofessional behavior through our actions is, therefore, great under these circumstances. Residents, fellows, and students will more readily emulate our actions than our teachings.
Reflective Learning.
Much has been written on how to overcome the tension between the “overt” and “covert” curricula in medical education as it pertains to professionalism. It has been suggested that the culture in today's hospitals and in many medical systems is antithetical to the development of the virtuous healthcare practitioner (6). One approach, applicable to practicing intensivists as well as trainees, is to develop a more reflective approach to ongoing behavioral learning (7). In this way, we acknowledge when our behavior is different from what is optimal, and we can identify reasons for that difference. Bringing this acknowledgment into our consciousness may prevent the discrepancy between the ideal and the real from turning into cynicism. As we become more reflective, we can utilize
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the stories that surround our involvement with our patients to help identify emotional issues in our own responses to them or their situations.
A specific approach, termed “narrative-based professionalism,” presents the opportunity to rectify the tension between tacit and explicit values (7); for example, between altruism and self-interest. In this scheme, young professionals are immersed in a wide array of narratives or stories that help to develop role modeling, self-awareness, narrative competence, and community service. In addition, the ACGME has offered some suggestions for teaching and assessing professionalism that may be found on their web site, where one can find access to numerous web-based resources for education, assessments (including 360-degree evaluations), and references (2). The ABP web site lists guidelines for how to evaluate professionalism of pediatric residents. One way to approach the teaching of professionalism and the core competencies is through simulation.
Professionalism Training Addressed through Simulation
As mentioned throughout this chapter, various scientific and regulatory bodies are becoming more interested in ensuring that physicians are intentionally trained in various aspects of professionalism. As a medical community, we are no longer content to assume that traditional training should result in physicians who are competent at procedures, effective and compassionate communicators, able to function as team leaders, and able to practice per consensus statements or evidence-based guidelines. The aviation, defense, and nuclear energy industries have a history of success in safety and skill-based performance improvement using simulation interventions in training. In 1999, the IOM specifically called for establishment of interdisciplinary team-training programs that incorporate efficient training methods, including simulation (18). Thus, interest has dramatically increased in identifying innovative mechanisms (such as simulation) to enhance traditional training methods and to measure the effectiveness of those methods.
Table 4.2 Types of simulation—examples from pediatric critical care
Type of simulation Examples from pediatric critical care practice
Standardized patients Training toward effective and compassionate communication: end-of-life discussions, autopsy, organ donation, obtaining consent, disclosure of errors, offering apologies, HIV exposure
High-fidelity mannequin Team training—cardiopulmonary resuscitation, difficult airway scenarios, shock management, elevated intracranial pressure management
Virtual reality Bronchoscopy, endoscopy, endovascular procedures
Partial-task trainer Airway trainers—bag-valve-mask ventilation and nasal and oral tracheal intubation, central-line chests, lumbar-puncture trainers, arterial-line trainers
Screen-based microsimulation Advanced Cardiac Life Support, trauma management, critical care scenarios
Simulation training has the potential to contribute to professionalism through a variety of mechanisms. First, following the credo of the Hippocratic Oath, our first obligation to our patients is to “Do no harm.” Effectively, this means that we must find methods to optimize our training; that is, to be the best doctors we can be and avoid “practicing” on our patients. One example is methods used to train how to perform procedures. The old mantra of “see one, do one, teach one” does a disservice both to the patient and to the physician in training. A growing number of published controlled trials demonstrate that physicians randomized to training programs that utilize simulation perform “better” (defined variably as faster completion of surgery, fewer errors made during a procedure, etc.) than those trained through usual programs, including those for laparoscopic surgery, vascular catheterizations, and early airway management (3,10,23). An example of a pediatric critical care procedure that could be practiced prior to performing on a live patient is placement of a central venous catheter. A new fellow could practice the myriad steps involved in successfully performing this procedure from beginning to end, including the steps that require communication with others. She could obtain informed consent, address whether or not the family should be present for the procedure, establish a sterile field, use ultrasound guidance to identify the vessel, practice the Seldinger technique, secure and dress the catheter, and document the procedure in the medical record. Increasing evidence demonstrates that simulation can shorten the time to competence and increase the likelihood that, when a physician is performing a procedure for the first time, the patient is safer than if the physician did not have simulation training.
Another important way in which simulation can be used to enhance professionalism is through various exercises focused on improving communication. One study utilized standardized patients with multidisciplinary intensive care teams to practice talking to families about issues such as delivering bad news, discussion of brain death, and approaching the family about organ donation (30). A national body funded this study, in which the exercise was well received by participants. The intervention was associated with increased organ donation rates, presumably due to more effective communication postintervention. Other types of communication that could be practiced using a standardized patient to enhance communication with a real patient or family member include: obtaining consent, discussion of withdrawal of care, request for autopsy, disclosure of errors, and delivering an apology.
Simulation can be used to diagnose deficiencies in team management of critical care issues and then, ideally, to address the issues identified in subsequent exercises. For example, mock codes have been used to identify deficiencies in the management of simulated pediatric trauma victims in the trauma bay and in simulated medical emergencies (8,14). These interdisciplinary exercises are a powerful means of observing team dynamics and assessing complex issues, such as leadership, communication, and adherence to important protocols (e. g., the American Heart Association's Basic, Pediatric, and Advanced Life Support algorithms).
Simulation can also be used to help assess competency. Most believe that it would be unwise to tightly link or require simulation performance to accreditation because little investigation has been conducted on the correlation between competent performance on a simulator, competent operational performance on real patients, and patient outcomes. However, it is already possible and advisable to assess whether a physician can adhere to accepted protocols as part of a training program. For example, programs can create scenarios with a high-fidelity simulator to test whether participants are able to follow consensus protocols on the management of cardiopulmonary arrest, difficult airway, shock, or traumatic brain injury with elevated intracranial pressure. Deviation from clinical protocols can be identified and addressed to improve protocol understanding and compliance and to employ a “train-to-success” approach.
The approach to simulation training has been categorized based on the different types of simulations used in the training. Simulation modalities can be categorized in a number of ways, one example of which is presented in Table 4.2. In addition to this type of categorization, the simulation community often uses the phrases “high-fidelity” and “low-fidelity” simulation. These terms have no universally accepted definitions. However, most would agree that “high-fidelity” simulators are more sophisticated and interact in some way with the user; for example, if the user delivers a medication to a “high-fidelity mannequin,” a computer can be programmed to have the mannequin's monitor respond appropriately, thus helping to “suspend disbelief.”
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However, the impact of the fidelity intensity (realism) of simulated scenarios on outcome is unknown and is an area for further study.
In creating a simulation program, it is important to match the type of simulation with the goals and objectives of the educational experience. Arguably, the most important component of simulation is the feedback. Corrective and directive feedback should be timely, constructive, and specific and may “slow the decay of acquired skills and allow learners to self-assess and monitor their progress toward skill acquisition and maintenance” (16). Ideally, if mistakes are made, the physician should be allowed to practice again until she achieves the expected outcome. Rather than walking away feeling deflated, she feels empowered.
Leadership
As mentioned earlier, one of the elements that can be taught through simulation is leadership. Leadership training is another way in which professionalism can be addressed and taught. Fellows entering pediatric critical care and pediatric anesthesiology training at a large children's hospital were evaluated on their knowledge of the “core competencies” (20). After investigators discovered that first-year fellows had a limited knowledge and understanding of the meaning and importance of the core competencies, they developed an educational program to teach the components of leadership that would help fellows to become competent in systems-based practice, professionalism, and communication skills. They discovered that (a) although fellows were willing to try to learn the material, they were not willing to devote much time to it, and (b) faculty members found it difficult to deliver the competencies within the existing structure. It also became clear to the investigators that faculty are not prepared to teach the competencies beyond the didactic level.
Other institutions are developing similar programs to address the competencies and help their fellows and faculty to develop stronger leadership skills. Such training differs from the standard “professional development” courses traditionally offered at schools of medicine, which are geared specifically to competency in research and teaching methods and to prepare for promotion. Although important for success within the medical school hierarchy, this traditional training may not be sufficient to improve clinical outcomes or to develop the kind of skills necessary to prepare trainees and practitioners to lead the diverse and rapidly changing subspecialty of pediatric critical care into the future.
What Is a Leader?
The definition of a leader can be complex. Most simply, it can be said that a leader is the person who “gets things done.” Achieving results is what we do in the ICU. It is also what we need to do in the meeting room if we expect to convince the hospital to buy that piece of equipment for our patients or in the unit if we want the resident to accomplish something in particular. Leadership is the way in which we achieve results. It is the way we empower others—and ourselves—and it is the way we ensure a better future for our profession.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the United States has published revisions of its standards that pertain to physician leaders in American hospitals. These are separate from the requirements it makes of medical staff in general (12). The new requirements are based on JCAHO's understanding of the relationship between leadership and the provision of quality healthcare, with an emphasis on patient safety. The medical staff of the hospital is identified as one of three components of hospital leadership, the other two being the governing body (such as the board of directors) and the management (also known as the administration). Medical staff must become intimately involved with developing the mission and vision of the institution, participate in developing safety and quality goals, and become involved in the budgeting process and interpretation of financial statements. The medical staff is expected to be knowledgeable about the population served by the institution, about applicable laws and regulations, and about their own individual and shared responsibilities and accountabilities.
Hospitals are responsible for orienting the medical staff leaders to these areas. In addition, each institution is expected to provide training for all leaders in conflict management, systems-based practice, team structure and function, evidence-based decision making, and development of mutual respect between disciplines. Each hospital that seeks accreditation will be expected to monitor the effectiveness of its leadership groups and to engage outside expertise (consultants) if
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adequate expertise does not reside within the institution for training and performance of the leadership tasks identified above.
These requirements will lead institutions to incorporate physicians into the overall leadership structure of the hospital to a much greater extent than most have done so far. With the growing need for physician leaders at all levels, the pediatric intensivist will have much to offer in terms of her understanding of patient needs, quality, patient flow, resuscitation, and other issues. The physician who has the proper training in several areas of management and leadership, who can apply systems-based ideals, develop evidenced-based medical practices, and oversee quality initiatives will be highly desired by those institutions striving to embrace these standards. Other valuable skills will clearly be effective communication and conflict management.
Leadership Training
Leadership training teaches individuals multiple skills, including time-management, effective communication, program development, visioning, and team development and leadership, to name but a few. Participants are helped to understand their “leadership style” through a number of possible mechanisms. Much of current leadership training is based on the development of what has been termed “emotional intelligence” by Daniel Goleman, a noted leader in executive development (9). Emotional intelligence is composed of four fundamental components: self-awareness, self-management, social awareness, and social skill. Each of these areas contains specific competencies to be developed. Different styles of leadership emphasize different patterns of emotional intelligence and, therefore, competencies. Because competencies can be taught and learned, it follows that effective leaders can be developed.
Most pediatric critical care fellows and junior faculty report that they have not received any formal training in management or leadership. They feel particularly unprepared to handle stress, manage conflict (within their own team or with other groups), manage time, and evaluate team performance (28). Leadership training is therefore clearly needed.
Leadership training exists in many forms and may be accessed in a variety of ways. Readers are encouraged to seek training at the local level when available. Numerous web-based programs are also available. One example is the leadership training presented by the American Academy of Pediatrics (AAP) and the Pediatric Leadership Alliance. AAP members can pay a fee and have access to this online training for a period of 3 years. It is available through the PediaLink Learning center found at www.aap.org. Another source of physician leadership information is the American College of Physician Executives (www.acpe.org). They provide quality publications and courses and can be helpful to those physicians who seek advanced degrees in management. Such individual courses that teach communication skills, management of conflict, and dealing with disruptive physician behavior can be accessed. Readers should not exclude attending seminars or lectures aimed at business professionals, because the basic concepts of communication, time management, stress management, and conflict management are applicable, regardless of specific work setting.
Numerous books have been written on the topics of leadership and management. One should decide whether she wants to develop personal leadership qualities or to learn more about organizational behavior and how to develop an organization (ICU, critical care division, family). A few recommended references are listed in Table 4.3. In no way can this list be exhaustive or even inclusive of the best in the field. Each “expert” in leadership development has her favorites. This list is therefore biased toward the interests of the authors. Absence from this list does not imply lack of value. New or trendy resources that might become outdated have intentionally been omitted.
Table 4.3 Suggested sources for leadership education
Web sites
Web site/URL Title/Description Limitations
American Academy of Pediatrics (AAP) www.AAP.org/ pedialink Pediatric Leadership Alliance Provides education on leadership styles, issues facing leaders, spends lots of time on team development and management; interactive; content is available for 3 years Cost to access the educational materials; available to both members and nonmembers; lower cost to members
www.Keirsey.com Temperament Sorter Temperament test based on the book Please Understand Me II; provides an interactive test to gauge personality types based on observable behavior patterns No cost, but registration may be required
www.personalitypage.com The Personality Page Provides access to simplified Myers-Briggs Type Indicator (MBTI) test on line Cost to register, $5; lots of additional links
http://typelogic.com Read about different personality types after taking the MBTI test or investigating your type some other way No cost; lots of links
Books
Author Title/Publisher Description
Allen, D Getting Things Done: The Art of Stress-free Productivity. New York: Penguin Putnam Inc., 2001 A not-so-basic introduction to time management and goal setting
Blanchard K, Zigarmi P, and Zigarmi D Leadership and the One-Minute Manager: Increasing Effectiveness through Situational Leadership. New York: William Morrow and Company, 1985 Easy steps to take to achieve leadership effectiveness in daily life and work situations
Blanchard K, Oncken W, Burrows H The One-Minute Manager Meets the Monkey. New York: William Morrow and Company, 1989 How to manage time, how to delegate, how to coach, and how to achieve efficiency and effectiveness
Collins, J Good to Great. New York: Harper Collins Publishers, Inc., 2001 Among other topics, looks at the qualities of leaders that allow some companies to make a leap into greatness
Covey SR The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. New York: A Fireside Book, 1989 The book that started it all; easy to read, discusses personal characteristics and their relationship to effectiveness at work as well as at home
Covey SR Principle-centered Leadership. New York: Free Press, 2002 Applying the principles of the 7 Habits to leadership and organizations
Covey SR The 8th Habit: From Effectiveness to Greatness. New York: Free Press, 2004 The way to “find your voice and inspire others to find theirs” and become a great leader
Fisher R, Ury W, Patton B Getting to Yes: Negotiating Agreement without Giving In. New York: Penguin Books, 1991 Every significant piece of communication can be a negotiation; this book shows how to do so effectively
Johnson S Who Moved My Cheese? New York: GP Putnam & Sons, 2002 Easy-to-read book that addresses how we do (or don't) embrace change
Katzenbach JR, Smith DK The Wisdom of Teams: Creating the High-Performance Organization. New York: Harper Collins, 2003 Discussion of how teams function and how to make them function better
Phillips DT Lincoln on Leadership: Executive Strategies for Tough Times. New York: Warner Books, Inc., 1992 Entertaining yet poignant examples of leadership choices culled from the life of Abraham Lincoln
Senge PM The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Currency Doubleday, 1994 How leadership can help guide your organization to change; includes a discussion on “team learning”
Ury W Getting Past No: Negotiating Your Way from Confrontation to Cooperation. New York: Bantam Books, 1993 More strategies on getting others to agree with you, and finding the best solution to avoid or manage conflict
Practicing Leadership through Management of Interdisciplinary Teams
To achieve a positive change in the medical society requires the physician to be both a “team player” and a “team leader.” Learning to work as part of an interdisciplinary team may be difficult for the physician, who is traditionally taught to function alone and assume individual responsibility. The fact that the interdisciplinary team is proving to be the best method to ensure that patients receive coordinated, appropriate care is recognized by practitioners of primary care, internal medicine, geriatrics, and other specialties. In an interdisciplinary team, members from various disciplines coordinate their efforts, communicating with each other directly, for the benefit of the patient and to achieve optimal patient outcomes (13). Pediatric critical care has long embraced the notion of the interdisciplinary healthcare team. We may therefore consider our subspecialty one of the “early adopters” and leaders within medicine. Our challenge now is to leverage our relatively loosely defined teams into highly functional teams that will achieve specific purposes.
Definition of Teams
Most of us think of a team as a “group of people working together,” usually with a common goal. However, recent business literature has defined a team more rigorously. A team is not just a committee or a working group. It is not a collection of individuals who want to “be a team.” An effective team is a group of individuals working toward a particular performance goal—a group of individuals more committed to team outcome than individual performance. An effective team functions with rigor and discipline. Its members have complementary skills, and they agree upon a common approach, while holding each other mutually accountable for their performance. The leader of the team does not direct the activities of the other members but works to build commitment, fill gaps, shift the leadership role as appropriate, and do real work beyond decision making (17). Unfortunately, the word “team” has become a buzzword in today's medical management literature as well as in everyday life, thereby losing some of its impact.
Functional Teams
The functional team we experience as we perform work rounds has a performance goal: evaluating the patients in as expeditious a fashion as possible, enabling patient care decisions to
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be made with the optimal amount of information and with appropriate attention to detail to prevent medical error. The overall goal of the team is to assist patients to recover from illness, injury, or operation so that they can leave the ICU at the optimal time. Each member participates by contributing her particular expertise. This is a team in which specific members are routinely assigned, not specifically chosen for their particular competencies. However, the leaders of the unit (medical and nursing directors) usually choose the general roles needed by the team.
By default, the team leader during rounds is generally the attending physician or the most experienced physician available. However, the team is much more effective if, at various points during the rounding process, the direct input of various members is fostered. The bedside nurse may be the most competent member to assess the level of the patient's pain over the course of the shift. The physical therapist is probably the most competent to assess the patient's likelihood of walking that day. The social worker is likely best equipped to address the needs of the family as they cope with the illness of the child, and so on. Input from all members of the team may be crucial when making certain decisions, such as whether to extubate the patient, transfer to the ward, or perform a tracheotomy. The child and the family will be the most important members of the team when considering end-of-life decisions in conjunction with the rest of the medical team.
In critical care, we cannot envision working without the interdisciplinary healthcare team. It has become a routine part of our practice. Unfortunately, in the health-professions literature, the value of health teams has been described and evaluated more in the primary care, elderly, and end-of-life settings and not in the critical care setting, suggesting that our subspecialty might be able to add considerably to the medical leadership literature.
Care must be taken to avoid confusing the interdisciplinary team with a multidisciplinary team. A clear hierarchy categorizes the latter; normally, the physician is the permanent leader, and most, if not all communication flows through the physician. Little direct interaction occurs between team members. The interdisciplinary team, on the other hand, functions by enabling and empowering each member of the team to interact with the others; it allows and encourages all members to contribute their expertise to the overall good. Direct and open communication occurs between and among the various disciplines, and each discipline respects and involves the others.
Units with a team-oriented culture appear to perform better, with shorter lengths of stay, better quality of patient care, and lower nursing turnover (28), but identifying such units may not be simple, because impressions of team culture differ between the physician and nursing staffs in a unit (29).
Developing a Functional Team
How does one go about turning the typical working group into a highly functional team? Many potential avenues are available. The remainder of this discussion focuses on recommendations from the business literature—specifically, issues identified by Katzenbach and Smith (17). Not all suggestions can be followed in every activity, but these authors provide numerous insights that may be applied successfully to the medical field. The authors identify the “team basics” that define the discipline required for optimal team performance. The team should be composed of a small number of individuals, usually fewer than 12. These individuals should possess complementary skills to ensure success for the task at hand. The team members must share a common purpose, a common set of specific performance goals, and a commonly agreed-upon working approach. Last, team members should hold each other mutually accountable for the performance of the entire team. The single, most important factor that guides team success seems to be a “clear and compelling performance challenge.” Sometimes, this performance challenge can be developed by the team members; at other times, it is defined by an outside individual, such as the hospital administrative officer. The role of the team leader has been identified as important but not critical. However, the leader's major goal should be to build commitment among all team members, fill gaps in knowledge or skills as necessary, shift the leadership role to other members as appropriate, and contribute real work in reaching team outcomes.
The overall performance ethic of the team often determines the difference between a team that consistently achieves its goals and one in which only random team successes are noted.
In many organizations, the significant danger exists of teams developing without the requisite discipline and rigor to ensure and sustain success. It is up to the team leaders as well as the organization's leaders to ensure that the discipline needed for team success is identified and supported.
In forming a highly effective team, it is necessary that the leader establish both the urgency and the direction of the team. All team members must believe that the team has an urgent and worthwhile purpose. Expectations should be clear. Members should be selected based on skills possessed and not on personalities. Katzenbach and Smith identify three categories of skills: technical and functional, problem-solving, and interpersonal. Sometimes, it is more useful to choose at least a few members who have the potential to develop the skills required if the rest of the team is willing to invest the time and energy necessary to help them to gain those skills. This is obviously true in the typical healthcare team scenario in which residents and students, novice nurses, and others are welcomed onto the team and assisted in learning the particular skills they need to ensure team success. The team should be challenged with a few immediate performance-oriented tasks and goals (getting the patient extubated, solving the problem of ventilator-associated pneumonia, enrolling patients in a new unit-based research study). The performance goals must include a clear “stretch” component, so that the team members strive for the desired result (such as eliminating catheter-related bloodstream infections or ventilator-associated pneumonia). Data must be made available to team members on a regular basis, so that they can benchmark their progress and degree of success. The team should congratulate itself when performance goals are met. Even though the team should be focused on communal success, it is important to acknowledge the individual contributions of each team member in allowing that success.
Teams sometimes get “sick.” A sick team can be diagnosed by a loss of energy or enthusiasm; a sense of helplessness; a lack of purpose or identity; presence of nonproductive conversations, cynicism, and mistrust; interpersonal attacks made
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secretively and to outsiders; and lots of defused responsibility when things go wrong. Team members may place blame on top management, on the remainder of the organization, or on the “system.” When these symptoms of a sick team are recognized, the following treatment options are available:
  • Revisit the basics; reestablish the purpose of the team.
  • Go for small wins—pick a few important items that are relatively easy to achieve (the proverbial “low-hanging fruit” often mentioned by executives) and give members a sense of accomplishment.
  • Bring in new information and approaches, such as external benchmarks or examples of other units that have achieved a goal similar to that on which you are working.
  • Take advantage of facilitators and training.
  • Change the team's membership, perhaps even the leader.
Conclusions and Future Directions
Professionalism is an area of today's medicine to which attention must be paid, both in the clinical arena and in the classroom. Only by paying attention to the development of renewed professionalism will our field and our subspecialty be able to thrive in the future. Research is necessary to determine the best methods by which to teach professionalism to our students and trainees and to evaluate the level of professionalism among practicing intensivists. However, use of role modeling, simulation, and leadership training is likely to be among our approaches to this very important task.
Leadership development and training is important to enhance professional development, improve patient care, and engage in systems-based practice. The core competencies become increasingly important as more attention is paid to these issues in credentialing, certification, and maintenance of certification. Leadership can be learned. Effective means of teaching leadership techniques have been developed by business, and these can be adapted to medicine. Additional research should be targeted toward assessing the effectiveness of the growing number of educational opportunities in this area.
The subsequent chapters in this section focus on many topics and skills that contribute to the development of effective leadership. The section editors and the authors of each of the chapters hope that the reader will find useful information and develop a working knowledge base of the competencies that will define the pediatric critical care professional in the 21 st century.
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