• 24% of all Canadian seniors report having 3 or more chronic conditions
• These seniors report
13.3 million healthcare visits per year
(CIHI, 2011)
Healthcare now.
Healthcare is a team sport.
Or a maze of care episodes?
What is our responsibility for the MAZE?
Are we training for collective incompetence?
Common educational assumptions & their unintended consequences
for healthcare teamwork
Lorelei Lingard, PhD
@LingardLorelei
Common educational assumptions & their unintended consequences
for healthcare teamwork
A rhetorical approach to assumptions
Every way of seeing…
is a way of not seeing.
(Kenneth Burke 1965)
Dominant educational assumptions are ‘ways of seeing’. They ‘select & deflect’ our attention. They create areas of robust attention, and blind spots.
Presenter
Presentation Notes
The ‘prison-house of language’ How we describe/frame the issue of competence influences our attitudes and actions. A limited language impedes our sense of what’s possible. Burke: “every way of seeing is also a way of not seeing” (THIS is the key point – these words should likely go on the screen” “language acts as a filter and screen. A limited discourse limits the possibilities of experience in ways that impede thought and action.
Objectives
• Consider 3 educational assumptions • Explore their blind spots • Discuss consequences for teamwork • Point to ways forward – both
comfortable & uncomfortable
Every way of seeing is a way of not seeing
1. Competence
Assumption
Competence is:
• a quality that individuals acquire and possess
• a state to be achieved
• context-free, untied to time and space
Individualist way of seeing Competence
Candidate Selection
Student Assessment
Licensing and Evaluation
Monitoring of Licensed Practitioners
Remediation
Individualist notion influences everything
Presenter
Presentation Notes
Remediate individuals on an individual basis Monitor licensed practitioners’ ongoing development through accrual of individual CME credits License residents based on examination of individual knowledge and skill Evaluate residents based on OSCE performances as Individual diagnosticians Assign individual grades to students (even in context of group activities such as PBL) Select candidates based on individual academic qualifications
In health professions education, “the dominant learning theories (adult learning, reflective learning, experiential learning) take the learner as ‘active agent’ at the center of the activity of learning.``
(Bleakley 2006)
Theoretical roots
Presenter
Presentation Notes
Bleakley, Medical Education 2006
Robust attention
Blind spot
Blind spot
A Story
Hospital physicians
Family doctor
Homecare case manager
Individual Competence
Presenter
Presentation Notes
Individual competence – that thing we’re tuning our entire medical enterprise to produce…
Individual Competence
≠ Good Healthcare
Presenter
Presentation Notes
… does not equal good healthcare. And that is a fundamental educational paradox that we have to come to grips with.
Collective Competence
Aspects of competence that are not reducible
to the individual but emerge instead
from social and organizational systems.
(Lingard 2009, 2012; Boreham 2000, 2004; Rogalski 2002; Weick & Roberts 1993; Kitto & Grant 2014)
Competence is
• a constantly evolving set of multiple, interconnected behaviors
• achieved through participation and enacted in time and space
Collective way of seeing Competence
Distributed cognition Collaborative work as ‘joint cognitive accomplishment not attributable to any individual’.
(Hutchins 1991)
Theoretical roots
Situated learning theory Competence emerges through social interaction, shared experience, development of tacit knowledge, and innovation in response to situated needs.
(Lave 1991; Eraut 2000; Mittendorf 2006)
Theoretical roots
We need both ‘ways of seeing’
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
NOT a simple binary opposition. Collective not a ‘solution’ to individual.
Each ‘selects’ and ‘deflects’.
Presenter
Presentation Notes
An appreciation of both could lead to a better language for describing (and assessing) “team competence”.
Ways forward: Assessing differently
Two ‘ways of seeing’ competence
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
Presenter
Presentation Notes
Collective competence isn’t acquired
Two ‘ways of seeing’ competence
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
Is trainee a good communicator? Does she demonstrate professionalism?
Presenter
Presentation Notes
Collective competence isn’t acquired
Two ‘ways of seeing’ competence
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
How well does trainee anticipate others’ actions?
Is trainee aware of what others know?
Does trainee adjust to
contextual constraints?
Presenter
Presentation Notes
How can start ‘seeing’ collective competence in our training and assessment?
Two ‘ways of seeing’ competence
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
How well does trainee anticipate others’ actions?
Is trainee aware of what others know?
Does trainee adjust to
contextual constraints?
Presenter
Presentation Notes
How can start ‘seeing’ collective competence in our training and assessment?
Two ‘ways of seeing’ competence
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
What anticipatory strategies does the team enact?
How does the team manage differences in knowledge?
How does the team adjust to contextual constraints?
Presenter
Presentation Notes
How can start ‘seeing’ collective competence in our training and assessment?
Two ‘ways of seeing’ competence
• Individual possession • Stable • Context-free
• Distributed capacity • Evolving • Based in situations
What anticipatory strategies does the team enact?
How does the team manage differences in knowledge?
How does the team adjust to contextual constraints?
Presenter
Presentation Notes
How can start ‘seeing’ collective competence in our training and assessment?
A bit of uncomfortable bedtime reading…
Every way of seeing is a way of not seeing
2. Problem solving
Assumption
Presenter
Presentation Notes
Problem solving happens in individual heads.
Assumption
Presenter
Presentation Notes
And problems hold still while our heads solve them.
Robust attention
Presenter
Presentation Notes
Robust attention to diagnostic reasoning, how expertise develops cognitively.
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Presentation Notes
There is a rich tradition of medical education research around the issue of how experts solve problems and how clinical reasoning develops. Scientists based in cognitive psychology have developed robust theories about the cognitive structures underpinning expert problem solving, and in fact MedEd curricula like PBL reflect this scholarship.
Blind spot
Presenter
Presentation Notes
Robust attention to diagnostic reasoning, how expertise develops cognitively.
Blind spot
Presenter
Presentation Notes
But what about when more than one expert is encountering the same patient problem?
A Story
Presenter
Presentation Notes
Read story – make it clearer that the reframing as a moral dilemma is impactful…
How problems are defined is as important as how they are solved.
Sayra Cristancho, PhD
Presenter
Presentation Notes
Introduce sayra’s work, her systems engineering orientation which emphasizes multiple perspectives, interactions among them, and their impact on how a problem is defined…
In teams, problems are defined in multiple ways
Presenter
Presentation Notes
Problems are not static but evolve… They look different depending on whose point of view we take, on which point in time we emphasize during the process, and on what another person is doing… For instance, in this story, a procedural problem for the surgeon shifted into a care access problem and finally evolved into a moral problem… This evolution of the problem happened because each team member defined the problem differently and consequently tried to solve the problem independently… however, every time they separately attempted a solution, that solution changed the nature of the problem which required a redefinition… This story of everyday, incremental problem solving and iterative problem definition is the sort that occurs regularly in healthcare, and it illustrates the fluidity of problems. In Derek’s story the issue of reframing problems was made explicit, but in everyday practice it most likely happens tacitly as clinicians balance their various priorities. Whether explicit or tacit, however, team members learn from such experiences. The next time this senior surgeon and oncologist interact regarding pre-surgical chemotherapy, each will make inferences about the other’s definition of the clinical problem based on this experience and adapt their behavior accordingly. The surgeon might, for example, admit the patient before consulting with the oncologist in an attempt to manage to avoid escalating the problem into a moral issue. As team members interact around shared patients, they should begin by acknowledging that not everybody will agree on the definition of the ‘problem’ by asking 3 key questions… What are all the relevant perspectives? How do those perspectives interact? How do team members adapt their definition of the problem as a consequence of those interactions?
Each definition prompts unique solution
Presenter
Presentation Notes
Problems are not static but evolve… They look different depending on whose point of view we take, on which point in time we emphasize during the process, and on what another person is doing… For instance, in this story, a procedural problem for the surgeon shifted into a care access problem and finally evolved into a moral problem… This evolution of the problem happened because each team member defined the problem differently and consequently tried to solve the problem independently… however, every time they separately attempted a solution, that solution changed the nature of the problem which required a redefinition… This story of everyday, incremental problem solving and iterative problem definition is the sort that occurs regularly in healthcare, and it illustrates the fluidity of problems. In Derek’s story the issue of reframing problems was made explicit, but in everyday practice it most likely happens tacitly as clinicians balance their various priorities. Whether explicit or tacit, however, team members learn from such experiences. The next time this senior surgeon and oncologist interact regarding pre-surgical chemotherapy, each will make inferences about the other’s definition of the clinical problem based on this experience and adapt their behavior accordingly. The surgeon might, for example, admit the patient before consulting with the oncologist in an attempt to manage to avoid escalating the problem into a moral issue. As team members interact around shared patients, they should begin by acknowledging that not everybody will agree on the definition of the ‘problem’ by asking 3 key questions… What are all the relevant perspectives? How do those perspectives interact? How do team members adapt their definition of the problem as a consequence of those interactions?
Each attempt at solution changes the problem
Presenter
Presentation Notes
Problems are not static but evolve… They look different depending on whose point of view we take, on which point in time we emphasize during the process, and on what another person is doing… For instance, in this story, a procedural problem for the surgeon shifted into a care access problem and finally evolved into a moral problem… This evolution of the problem happened because each team member defined the problem differently and consequently tried to solve the problem independently… however, every time they separately attempted a solution, that solution changed the nature of the problem which required a redefinition… This story of everyday, incremental problem solving and iterative problem definition is the sort that occurs regularly in healthcare, and it illustrates the fluidity of problems. In Derek’s story the issue of reframing problems was made explicit, but in everyday practice it most likely happens tacitly as clinicians balance their various priorities. Whether explicit or tacit, however, team members learn from such experiences. The next time this senior surgeon and oncologist interact regarding pre-surgical chemotherapy, each will make inferences about the other’s definition of the clinical problem based on this experience and adapt their behavior accordingly. The surgeon might, for example, admit the patient before consulting with the oncologist in an attempt to manage to avoid escalating the problem into a moral issue. As team members interact around shared patients, they should begin by acknowledging that not everybody will agree on the definition of the ‘problem’ by asking 3 key questions… What are all the relevant perspectives? How do those perspectives interact? How do team members adapt their definition of the problem as a consequence of those interactions?
Ways forward: Adaptive expertise
• Attends to how experts innovate in practice in response to non-routine problems
• Acknowledges situated-ness of problem solving
Ways forward: Adaptive expertise
• Attends to how experts innovate in practice in response to non-routine problems
• Acknowledges situated-ness of problem solving
Because…
• Adaptive expertise retains an emphasis on the individual
(Mylopoulos & Regehr 2011)
Ways forward: Distributed cognition
• Treats problem solving as co-construction of individual & their environment
• Problem definition and solution are iterative, relational processes that no individual controls
(Orlikowski 1997; Bereiter 1999)
Ways forward: Distributed cognition
• Treats problem solving as co-construction of individual & their environment
• Problem definition and solution are iterative, relational processes that no individual controls
(Orlikowski 1997; Bereiter 1999)
A bit of uncomfortable bedtime reading…
Every way of seeing is a way of not seeing
3. Teamwork
Assumptions
Teams pull together, not apart
Presenter
Presentation Notes
To teaching professional roles in IPE, and to techniques to foster shared goals among team members. Capra 1996; Stacey 2006; Lewin 1999;
Robust attention: IPC/IPE
Blind spot
Presenter
Presentation Notes
Fenwick 2012; Bennett 2010; Zimmerman 2002) It oversimplifies the story of why teams come into conflict and tension.
A Story
Presenter
Presentation Notes
Ethan had been diagnosed 3 years previously and he was in NYHC Stage III heart failure at the time of his interview. His TSU included his wife, the heart function clinic nurse practitioner, and two cardiologists, one of whom specialized in supportive care. As an example of convergence, Ethan understood that the root of his heart condition was amyloid disease, and his wife, cardiologist, and heart function clinic nurse agreed on this fact. Furthermore, the entire team shared an understanding that Ethan was deeply unhappy with his loss of function, especially having led a ‘‘very active lifestyle’’ prior to contracting his heart condition. On the other hand, the team diverged on the importance of meeting Ethan’s psychosocial needs. Ethan identified his ‘‘mental issues’’ as one of his main problems. His cardiologist, however, questioned the value of ‘‘sitting down with a counselor once a week and talking about how depressing it is that you’re dying’’. Meanwhile, his supportive care cardiologist described his belief in the importance of a ‘‘two-pronged’’, approach to patient care for Ethan, where pharmacological and non-pharmacological approaches complement each other. Ethan’s wife expressed concern that his ‘‘moods’’ were not being addressed ‘‘at all’’
“There was anesthesia, cardiology and us. And ourselves and anesthesia felt that the patient needed a left-sided heart cath prior to listing for transplant, and cardiology disagreed with that.” (Transplant Nurse Practitioner)
(Lingard et al, Med Ed, 2013)
“Cardiology was ordering a CAT scan and it was coronary arteries, and anaesthesia said, ‘I don’t care what the result is, that isn’t good enough, we want a cath.’ And the cath guy says, ‘well I’m not doing a cath because you don’t need a cath’, and anaesthesia says, ‘well, we’re not doing a transplant then’. And we’re stuck in the middle going, ‘guys, figure this out’.” (Transplant Staff)
“Sometimes the comment is made by cardiology that anaesthesia is being overly cautious, and anaesthesia’s saying, ‘well cardiology’s not in the O.R. and they don’t know everything that we have to deal with.’” (Transplant surgeon)
“The compromise between all 3 services is to order a CT angiogram, which is performed in radiology. But then the radiologists wanted the heart-rate to be much better controlled prior to doing a CT coronary angiogram because they felt that the false-positive rating would be too high with a high heart-rate, and so they didn’t want to do the scan.” (Transplant Fellow)
“We’re a good team – we like working together, we’re committed. This sort of thing happens. It’s complicated – save the patient, steward the organ – nobody knows what the ‘right’ answer is in this case because there isn’t one. And where we get into trouble is when somebody wants a quick fix. There’s no such thing, and this time’s fix will not be the same as last time or next time. With Mr. Chang, anesthesia didn’t agree with cardiology, but they decided they trusted the surgeon. And, ok, I would have liked it to go quicker, but then also, sorting through everyone’s concerns maybe makes for a better decision in the end.”
(Transplant Nurse Practitioner)
Presenter
Presentation Notes
Ethan had been diagnosed 3 years previously and he was in NYHC Stage III heart failure at the time of his interview. His TSU included his wife, the heart function clinic nurse practitioner, and two cardiologists, one of whom specialized in supportive care. As an example of convergence, Ethan understood that the root of his heart condition was amyloid disease, and his wife, cardiologist, and heart function clinic nurse agreed on this fact. Furthermore, the entire team shared an understanding that Ethan was deeply unhappy with his loss of function, especially having led a ‘‘very active lifestyle’’ prior to contracting his heart condition. On the other hand, the team diverged on the importance of meeting Ethan’s psychosocial needs. Ethan identified his ‘‘mental issues’’ as one of his main problems. His cardiologist, however, questioned the value of ‘‘sitting down with a counselor once a week and talking about how depressing it is that you’re dying’’. Meanwhile, his supportive care cardiologist described his belief in the importance of a ‘‘two-pronged’’, approach to patient care for Ethan, where pharmacological and non-pharmacological approaches complement each other. Ethan’s wife expressed concern that his ‘‘moods’’ were not being addressed ‘‘at all’’
What makes teamwork so complex?
What makes teamwork so complex?
• 3 contributing factors
What makes teamwork so complex?
• Roles are overlapping
What makes teamwork so complex?
• Roles are overlapping • Authority is negotiated
What makes teamwork so complex?
• Roles are overlapping • Authority is negotiated • Competing goals exist
Ways forward
Are we using the IPC framework to reflect and teach this complexity?
Or are we simplifying?
Ways forward
Ways forward
Understand one’s own and others’ roles on the healthcare team.
Ways forward
Understand one’s own and others’ roles on the healthcare team.
Machine metaphor
Complex system metaphor
Ways forward
• Use IPC initiatives to focus on relationships among the parts, not the parts themselves
• Build complexity in: role overlap, negotiated authority, competing motivations
• Move training into practice settings • Develop faculty ability to constructively reflect
on practice tensions w/ learners
A bit of uncomfortable bedtime reading…
Summary
We are contributing to the MAZE
Because our common educational assumptions
are fundamentally individualist.
1. Competence is in individuals. 2. Problem solving happens in heads.
3. Teams are machines.
We need to shift from an exclusive focus on individual competence
To a recognition of collective competence as system property
Blind spot We need to shift from problem solving in individual’s heads
Presenter
Presentation Notes
Robust attention to diagnostic reasoning, how expertise develops cognitively.
To a recognition that multiple perspectives continuously reconstitute the problem
Presenter
Presentation Notes
But what about when more than one expert is encountering the same patient problem?
We need to shift from a machine metaphor of teams with stable parts/roles
To a To a recognition of teamwork as a negotiation among fluid positions
We need to challenge & expand our dominant, individualist educational assumptions
So that we can start training for collective competence.