One skill trauma professionals can teach the rest of medicine

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In my experience the best trauma care is, well, boring. It’s quiet and methodical. That’s because the best trauma team is organized and communicates well. There’s no excess motion.

For those of us who are used to being in the ED and the trauma bay, this is nothing new. However, if you spend your time in a different environment — as I have over the last few years — this kind of teamwork can be far less common.

Dr. Tom Lee is Chief Medical Officer at Press Ganey Associates, currently on leave from his roles at Harvard Medical School and the Harvard School of Public Health. He also happens to be a dear friend and mentor. When I was a resident, Tom shared with me a great article about physician leadership in which he began:

“The problem with health care is people like me — doctors (mostly men) in our fifties and beyond, who learned medicine when it was more art and less finance. We were taught to go to the hospital before dawn, stay until our patients were stable, focus on the needs of each patient before us, and not worry about costs. We were taught to review every test result with our own eyes — to depend on no one. The only way to ensure quality was to adopt high personal standards for ourselves and then meet them. Now, at many health care institutions and practices, we are in charge. And that’s a problem, because health care today needs a fundamentally different approach — and a new breed of leaders.”

Some of Dr. Lee’s comments are provocative and some may come as a surprise to those of us with experience on trauma teams. While we certainly arrive before dawn and stay until our patients are stable, we’re used to sharing the load with colleagues in a variety of ways: reviewing imaging and diagnostics, communicating with families, even performing procedures.

Now, I’m not saying we’re perfect, but we do have a powerful commitment to team-based care. I’d go so far as to say we can’t really practice trauma care without teamwork. So what makes trauma different, and what can we teach our colleagues?

First, in a trauma team, each team member has a specific, well defined role.

As you know, there is typically one person responsible for airway, another for exposure, another for vascular access, etc. The same can and possibly should apply in primary care: one person for registration and vital signs, another to ensure all required information is at the bedside, another to document, and another to execute the care plan and ensure appropriate follow-up after the clinic visit. We’re beginning to see these types of practices (such as ours at Oak Street Health) thrive, but this type of team-based care remains the exception and not the norm.

Second, these roles demand that trauma physicians delegate critical activities to others.

By its very nature, trauma care necessitates delegation. One person simply can’t do all that is required simultaneously with his/her own hands. As you might imagine, this approach is often new to other venues of care. This kind of delegation flies in the face of the traditional “review every test result with our own eyes” mantra, and many physicians are justifiably uncomfortable with the anxiety and especially the medicolegal risk it seems to invite. However, delegating responsibility for patient care objectives may counterintuitively reduce exposure by improving outcomes and instilling ownership and accountability among teammates. In other words, a nurse specifically tasked with and held accountable for completing a blood transfusion may be more likely to deliver than a physician with numerous other objectives and no support. Other specialties would certainly benefit from this type of divide-and-conquer approach to complex patient care.

Finally, trauma teams rely on closed-loop communication.

It’s exactly this style of communication that enables accountability and delegation. “Anne, please place a chest tube on the left side.” “Okay, Dr. Jackson, I’ll place a chest tube on the left side and confirm when it’s complete.”

Through that simple instruction-acknowledgement structure, trauma teams ensure coordination. When a situation changes, closed-loop communication allows the team to pivot in a synchronized fashion. We’re just beginning to see this in primary care, where providers are increasingly taking on a leadership role in coordinating the entirety of care in the outpatient setting — as virtually required by new value-based payment initiatives.

A handful of recent studies have looked at the phenomenon of teamwork in theory and in practice:

  • According to a study in the current issue of the Journal of Trauma and Acute Care Surgery, trauma teams that prepare with structured pre-arrival briefings are more aligned on anticipated acuity/injury severity.
  • A 2010 study published in the Journal of Surgical Education found that structured team training improves performance during trauma resuscitations as measured by a standardized evaluation instrument.
  • A qualitative study published in the Annals of Internal Medicine examined hospitals with high and low mortality rates in treating acute myocardial infarction (a good non-surgical equivalent of a trauma activation). The authors found that high performers were characterized by an organizational culture that supports efforts to improve care across the hospital — and not by prestige, brand or other qualitative features.

This emerging literature suggests communication and team-focused cultures matter. Yet as Dr. Lee says in his article, “Working in teams does not come easily to physicians, who still often see themselves as heroic lone healers.” That’s true in many cases, but trauma stands out as a specialty where team-based care thrives due to clearly defined roles, delegated responsibility and intentional communication.

As such, I’d encourage trauma providers to share this news and their skills with their non-trauma colleagues, and to have open discussions about the very reasonable anxiety it can provoke. It’s ultimately better for providers to practice in a supportive, collaborative environment. And the best news of all: evidence is beginning to show that this kind of far-reaching teamwork is better for patients too.

Dr. Griffin Myers is a board certified emergency physician, entrepreneur and nationally recognized thought leader in healthcare innovation and value-based care. His writings do not substitute for professional medical advice, diagnosis, or treatment. No patient relationship is created by your use of this content. You can find this and other media at his website: www.griffinmyers.com.

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