One of the central tenets of the patient safety movement is that modern medicine is a team sport. Unfortunately, its players – particularly physicians – were trained and socialized to be free-spirited individualists. We need the Celtics of the 80s; what we have is a collection of young John McEnroes.
While this theory has been generally accepted, there is less agreement regarding how to change things. When I speak about safety culture, many of the questions I’m asked focus on how we are going to train future generations of medical students and residents to be “different” (translation: not like the prima donnas I have to deal with in my daily practice). It’s as if people are fatalistic about the ability to transform the culture of today’s practitioners; perhaps the next crop of physicians will do, and be, better.
Those of us who aren’t resigned to a biological solution to this problem have been enthusiastic about teamwork training and crew resource management programs for years. These programs are modeled on similar programs introduced in aviation in the 1980s after it was discovered that several tragic crashes had their roots in remarkably poor teamwork and communication. The programs bring together multidisciplinary groups to learn habits of clear communication and teamwork, and to be trained in the use of tools to employ when the going gets tough – such as, say, when a flock of Canadian geese flies into your jet’s engines.
Five years ago, with funding from the Moore Foundation, we implemented such a program on the medical services at UCSF and at two nearby hospitals. Unfortunately, while the program’s participants believed that it made care safer, our relatively small numbers of patients and providers left us unable to show improvements on hard outcomes like mortality. Other studies have had similarly mixed results – enough to keep the candle burning for those of us who believe that culture is critical and that teamwork training is the likeliest way to improve it, but not enough to catalyze a national movement for more. And, because it is expensive (the outlays for the trainers are only a small fraction of the costs – the real costs are the lost productivity of scores of nurses and doctors taking a day away from their regular jobs), teamwork training has mostly remained a novelty, implemented by a few cutting edge institutions and true believers.