News
2015; Lippincott Williams & Wilkins; Volume: 37; Issue: 11 Linguagem: Inglês
10.1097/01.eem.0000473166.62356.b1
ISSN1552-3624
Autores ResumoFigureFigureWe work in a tribal jungle in health care. All the different professions, specialties, and departments, we all have our own subtle tribal culture, language, and even tribal dress. Perhaps this is an inevitable consequence of the complexity of health care today, but it means that my toughest days at work are not always the ones that people think. It's not the technical challenge of the high-octane trauma or end-of-life discussions. It's not even when I make a mistake. These things are tough, but they are the things for which we trained. I'd like to think that I can do a half-decent job of that kind of thing after 20 years. No, my toughest days at work are when the dark side of tribalism comes out. When an intern is being yelled at for not ordering the serum rhubarb that is so important to the internist tribe. Or when doctors and nurses think they are too special to say please or thank you. Or when the junior doctors are trying to sell their patients to different tribes using the correct tribal language. Even my own colleagues talking about the idiot inpatient registrars (residents). This is the dark side of tribalism in health care. But I know our tribalism has a good side. I put on my black scrubs and go to work, and I feel like I belong. The strong bonds I have with other emergency physicians and nurses make me do a better job each day. My tribe is great; they do exceptional things, and they help lift me to do more than I think I can. With tribalism in mind, I'd like to share a story that I used to tell with pride. It was 4:30 one afternoon, and I'd just received the evening shift handover. One of the patients was an elderly lady going to the operating theater. She had been in a motor vehicle crash and had a few injuries, including a vascular one. The vascular resident had seen the patient and was writing his notes. I then received a phone call from radiology saying the woman also had an unstable cervical spine fracture. I think to myself, Well, that's fine; she still has her hard collar on, but clearly this is information I need to share with the treating team. Consider this conversation with health care tribalism in mind. “Uh, hi. I'm Victoria. Have you got a minute?” I say to the vascular registrar. “Yep.” He doesn't look up. “Hi, I'm Victoria. I'm the emergency consultant. I need to speak to you about Mrs. Jones.” [Sigh] “Yes?” He still doesn't look up. This is not going well, and you can just imagine my rising anger at the disrespect being shown. Of course, by now an intern and a couple of nurses are watching, and tribal pride is on the line. I'd like to tell you that this ended well, but this is what I actually did. “Mate, this is the bit where you say, ‘Hello, my name is, how can I help you? Or do you need to go back to kindergarten?!’’ As I said, I used to tell that tale with pride, especially to my ED tribe, and, of course, I did have a point; he should have been more polite. But actually this is me showing the darkest of dark tribalism. I have long since forgotten what happened to that patient, if I ever knew, or to the vascular registrar. But, boy, have I told that story in the tea room a few times. And I know now what I've been doing is bonding with my tribe against the enemy: idiot inpatient registrars. And, more malevolently, I'm elevating my own position in the tribe while I boast about how I can be just as nasty and insulting as the best in my tribe when it comes it comes to those idiot inpatient registrars. The dark side is actually more subtle than we think. Bonding Experience The management of upper GI hemorrhage was studied at our institution a few years ago, looking at the patient journey and at the different treating groups involved: emergency medicine, medicine, gastroenterology, endoscopy nurses. The researchers interviewed many people and looked at notes. They had many interesting findings, but conflict came up a lot. One of the emergency specialists described how he felt about managing conflict in this context: “I think everyone likes to have a little team allegiance. And having a common enemy is a really great bonding experience for a team.” That was me. There I was again, building my team based on a common enemy. This is well described, not just in health care, but also in the book Tribal Leadership by David Logan, John King, and Halee Fischer-Wright, in which they describe the five levels of how groups or teams or organizations operate. (Harper Business, 2011.) Not surprisingly, the first three levels are very dysfunctional teams, but level 4, the kind of thing that I was doing in these cases, is actually quite a functional team. This team works together; they feel good about each other. But they built their team by having common enemies and by putting other people down. It's a classic charismatic, narcissist approach. Sadly, I am apparently good at it. Let's bring it back to patient care, and continue our focus on tribal interfaces. One of the things that is important to our tribe is time: the downtime in cardiac arrest, the golden hour in trauma (if you believe that anymore), the four-hour rule waiting times in the ED. Some of this is for good reason. A patient having a STEMI is more likely to live if we get him to the cath lab faster. A septic patient is more likely to live if we administer her antibiotics sooner. Consider another case. Amy is an ED registrar who worked in a hospital without a cath lab upstairs. She and her consultant were treating a 62-year-old woman who presented with vague, posterior left shoulder pain. The triage staff were right on it, brought her into acute, and did an ECG showing critical coronary artery occlusion. Amy and her consultant knew this was an acute coronary syndrome. She needed to go to the university hospital, so Amy called the interventional cardiologist, who agrees with the ED interpretation of the ECG but wants us to keep her until a bed is ready, probably tomorrow. Our version of right is that she needs to get to a cath lab now. If Amy were in front of you and you were trying to control your emotions, what advice would you give her? First, you would ask if she had done a nice SBAR, which is beautifully structured communication but not much good if someone isn't listening. Then you might suggest she develop a rapport with this cardiologist. If that didn't work, you'd say, “Tell him your consultant said....” And then if that didn't work, we would pull out our trump card, and suggest she say, “We just want what's best for the patient.” It's understood that you are also saying, in brackets, “And you don't.” These are classic negotiating strategies, some more effective than others, but there is a basic problem we often don't accept when working at our tribal interfaces: There is often more than one version of right. We don't know the cath lab's priorities or the other patients who might need that care. Simply pushing our right even harder isn't helpful. Even if we do win in these conflicts, maybe we lose in the long run. We must trade off the goal we are trying to achieve with the relationship of the person with whom we are negotiating. If it's a goal of low importance and a not-very-important relationship, you're going to avoid it. Pull Up a Chair We in health care tend to think that the patient goal is everything, and our relationship with our colleagues is less important, especially if they are from another tribe. But pretty much all of our negotiations depend on both goals and relationships: Whatever happens with this patient, we have future patients to consider, and building our relationships becomes almost as important as our patient goal. But there is one that we typically wouldn't suggest, and it's pretty important: Simply pull up a chair. It changes the dynamic when we sit down to talk to people. Our patients tell us this. They perceive we spend more time with them and understand them better when we sit. It's the same when we're negotiating, and it's not just a perception. We are more likely to listen if we sit down. Can we do more? Granted, there is only so much to do at 2 a.m., no matter how sophisticated our negotiation. But we need to build those relationships in the long term. We need to take every opportunity to build these bonds. Go to radiology, and say, “Hello, my name is, and I'm on shift tonight.” And don't have a request form with you the first time. Just try to be human about the interactions that we have at work every day. Look for opportunities in research, in education, in advocacy. These are obvious opportunities for us to build relationships across tribes because we can build those away from the hot zone of the patient, and actually get to know and trust people. The second thing we need to do is actually walk the walk with our juniors. We need to be able to say to them that the other tribes are great. We need to lift ourselves up to Tribal Leadership's level 5. What do level 5 teams do? We make our tribes in competition withwhat's possible, not another tribe. And every now and again, when we go to war — because sometimes we have to — we can make sure we are balancing out the risks to the goals and to the relationships. Yesterday, I was asked what you do when you want to change someone's world view. I don't know the whole answer, but I suggest we start with sitting down, and saying, “Hello, my name is Victoria. My tribe is great, and so is yours.”
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