Improve teamwork with better selection of medical trainees

Amid the many ongoing changes to health care, it’s clear that better teamwork is needed in American medicine. Calls for stronger interdisciplinary collaboration have permeated position statements and policies, and organizations have begun redesigning care processes to include novel team-based approaches. Emerging data continue to affirm that strong teamwork and communication can increase the value of care.

Of the many efforts to improve teamwork, however, one potential area for significant improvement remains: the selection of medical trainees.

Traditionally, there has been little debate about how to evaluate academic competency in medical education. Grade point averages in undergraduate science classes and scores on the MCAT are widely accepted benchmarks for medical school admissions, as STEP board scores and clinical rotation grades are for residency applications. Nuances based on an applicant’s background certainly still exist. Humanities and bioscience majors must be evaluated differently, as must medical students with health policy or basic science experience. However, differences are still interpreted largely within the context of standardized testing and grading metrics.

For better or worse, this hasn’t been true in the evaluation of personal competencies. Despite conceptual agreement about the characteristics that future physicians should embody (e.g., compassion, empathy, interpersonal skills, and emotional awareness), there is still relatively poor agreement about how to “get there” by relating progressive development of those traits with the selection process. Some data suggest that specific qualities are linked with positive admissions outcomes while other data reveal that in fact dozens upon dozens of different personal characteristics are considered.

This variability poses a challenge for building stronger clinical teams. In selecting and training learners, no educator would deny the importance of interpersonal skills or the ability to work well on teams. Evaluations throughout medical school and residency training appropriately include assessments of whether a trainee is a “team player,” and the admissions process itself in large part aims to ensure a good applicant-program fit.

The problem is not mainly that we fail to recognize teamwork as a key part of training and clinical care. More of the issue lies in how we frequently understand and define the phrase “being a team player.” Medical education has traditionally been siloed: Medical, nursing, pharmacy, and physical therapy students learn along parallel, non-intersecting paths. Residency training is similarly marked by divisions between disciplines. If teams are always conceptualized within traditional care structures, progress will be slow. Instead, we need creative approaches to shift focus away from individual clinicians and specialties toward group skills and collective performance. A number of groups are beginning to make progress along these fronts, and more is needed.

Beyond framing problems, however, lies an even more central issue: the underlying (and inadvertent) discordance between what we say we value in choosing medical trainees and what we actually convey through our actions.

A quick glance at common medical school application requirements underscores this point. Most lists include heavy doses of biochemistry, cell biology, physics, and other natural sciences — requirements that make good sense. Upon further consideration, however, glaring omissions emerge. The courses and experiences that enable reflection, social awareness, and teamwork (e.g., ethics, psychology, social studies, humanities, and volunteerism) are often encouraged for admission but are not required or codified in the selection process. Recognizing the need to choose strong team players and communicators is one thing; hardwiring these values into our decisions is another.

To be clear, a solid grasp of pathophysiology is part of the foundation of good doctoring, and much good has come from in-depth biomedical investigation. However, almost all medical students can attest to hours poring over biochemical pathways, histological stains, and intricate regional anatomy (brachial plexus, anyone?), only to hear professors and mentors quip: “Oh, don’t worry, you’ll forget almost all of this by the time you begin residency” or “You learn all of that now, but a lot of it isn’t clinically relevant.” A few years of residency training rapidly validate this suspicion, affirming that much of the pathophysiology we learn is (either willfully or inadvertently) lost along the way.

More than a criticism of specific disciplines, then, this should be a recognition that underemphasized domains in trainee selection can counteract efforts to build better teams, that there is room to replace things that “won’t be clinically relevant” with skills that decidedly will, and that we can do better in aligning our explicit values with our implicit priorities about team players. If we truly mean to train physicians who work well with others and put the interests of the group ahead of their own, perhaps we need to adjust the kind of applicants we target. Change will be incremental, but worthwhile.

To encourage progress, educators can employ several strategies, including modification of admissions requirements, careful “blurring” of roles, implementation of group evaluation and benchmarks, and use of teamwork-focused interviews. By adding more rigorous non-science requirements and placing premiums on experiences in teamwork and collaboration, institutions can both implicitly and explicitly reinforce their importance. By shifting certain roles away from individuals and toward groups, more emphasis can be placed on what the team — not any one person — can accomplish for collective patient good (e.g., diagnosis or the creation of management plans). By creating group evaluations and benchmarks, educators can underscore that teams should comprise whoever is required to accomplish the task at hand (not just those in a similar specialty) and that the group dynamic results from each member’s individual contributions. By focusing on questions related to teamwork (e.g., “Tell me when you sacrificed your own good for that of a team; describe the biggest mistake and achievement you’ve made as a member of a team”) rather than individual merit (e.g., “Tell me about your greatest accomplishment or strength”), educators can better approximate how an applicant will mesh with a diverse group of colleagues.

Regardless of strategy, one thing is clear to those who recognize the importance of excellent clinical teams: Change often occurs out of necessity. If pathways to becoming a doctor continue to largely demand individual achievement — years of compiling stellar individual test scores, grades, accomplishments, distinctions, and expertise — it will be hard to convince many learners of the need to change at all.

That we still have great gains to make in interdisciplinary teamwork speaks to the fact that “every system is perfectly designed to get the results it gets.” To reap the benefits of better communication and teamwork, we must mind what we sow. To use these rewards to produce better patient outcomes, we must improve teamwork by testing new ways of selecting medical trainees.

Joshua Liao is an internal medicine fellow and can be reached on Twitter @JoshuaLiaoMD and his self-titled site, Joshua Liao. This article originally appeared in ACP Internist.

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