In May 2017, I started to reflect on my own personal views of wellness and the importance of the team. Since that time I have been fortunate to speak with members of frontline clinical teams from four different practices:
•Eric Tetzlaff, MSH, PA-C, and Michael Hall, MD, MS, of Fox Chase Cancer Center
•Megan Schriner, PA-C, and Ryan Ramaekers, MD, of Saint Francis Cancer Treatment Center
•Robbe Peetz, PA-C, MS, of Fred and Pamela Buffett Cancer Center
•Abey Mathai, PA-C, and Alma Rodriguez, MD, of The University of Texas MD Anderson Cancer Center
During these conversations, I spoke with physicians and advanced practice providers (APPs). I wanted to know about their practice, who they consider to be on their team, what they thought of team wellness and its impact on the individual, how they recognize burnout, and what they do to address burnout or at least mitigate it. All of the teams found this topic an easy discussion and, without hesitation, they were able to speak at length on all of these questions. This made me realize that more people—at least at these four practices—have been thinking about team wellness.
What was striking to me, and this may be a random chance or simply common elements of how people interact on teams, were the following ideas that came up during each conversation without prompting from me:
•Physical proximity seems to matter to the team
•Frequent communication was identified as a positive influence on team function
•Mutual respect contributes to positive team wellness
•The team dynamic can increase burnout or protect against burnout
•The concept of how shared burden mitigates burnout
•Informal communication methods and backup behaviors appear to be common
To be clear, this was not a randomized and controlled study of human behavior. At best, this represents individual thoughts and qualitative data from four teams as well as my own reflections. I also have to admit that it was cathartic to speak with others who have shared experiences and ideas that are concordant with my own. Whether this represents further random chance or possibly common elements of human nature, I can’t say.
Why does proximity matter? How does it contribute to the team? According to Dr. Rodriguez, “Proximity to each other adds to our teamwork and communication and helps us learn about team members’ work styles.” What seems to matter most about proximity is a sense of shared experience in real time and the ability to physically connect, observe, listen, and simply sense what is happening to others and respond. Ms. Peetz identifies another facet: “Proximity and seeing each other daily—and a big candy dish—keep the team going, keep it fun, and make it easy to communicate.” I can recall my own experience when my patient scheduling coordinator (PSC) sat with the team in clinic or sat in a large office more than 100 yards
away. It frequently seemed that I was more of a team with my PSC when she was with me—in the trenches—trying to get through clinic. As if this proximity meant that we were really in it together.
Frequent communication was a common element in the teams I interviewed. There are formal elements, including electronic health record communications and multidisciplinary case conferences, such as “meeting several times a week to run through patients and then formally once a week to go over treatment plans,” according to Dr. Ramaekers. Some teams used other mechanisms with greater frequency. According to Dr. Hall and Mr. Tetzlaff, “We don’t have regular meetings for communication, we use easy communication lines such as texting and phone calls.” The concept of checking in and keeping communication lines open was attributed to “helping team members take action as needed to keep things moving for patients and debrief when issues arise,” according to Mr. Mathai. In the interviews, it was common for teams to report communicating frequently with each other either through formal or informal mechanisms and to attribute this to feeling connected and being collegial.
Speaking about the team brought out several different concepts of respect in the four practices and resonated differently with physicians and APPs. Dr. Rodriguez summed up her concept of respect when she stated that the “personality of our team members is critical—when they align it makes the team strong, we are all willing to pitch in and do what it takes, and we don’t take ourselves too seriously and don’t act like prima donnas.” Other physicians, such as Dr. Hall, spoke about protecting the team—as he put it, “Physicians need to defend APPs, don’t allow the dumping of work on team members, and hold people accountable in the team for their roles.” For APPs, Ms. Schriner said, “The physician-APP relationship is important and must be collegial—you can’t lose your temper.” I can add from my own experience that when I felt respected in my team I was more likely to give extra effort and view work from a more altruistic perspective.
There was mutual agreement from all of the individuals that I spoke with that the concept of team wellness does impact burnout. According to Dr. Hall, “Team function has an enormous impact on your sense of control and worry about patients.” Some reported that working in teams is what attracts them to medicine. Ms. Schriner said, “As an APP I really like and look for the team concept—that is why I became a PA.” Ms. Peetz took the concept of team wellness to a more personal level: “I come to work because I have a great team, and that keeps us all well. We feel like family and look out for each other.”
Another common recognition was how the team can impact individual burnout. As Mr. Tetzlaff stated, “The chain of burnout impacts everybody.” Taking this further into the concept of a team of teams, Mr. Mathai said, “Team wellness matters. Dysfunction from teams can impact us individually and spill over into other teams.”
Oncology can be a very demanding practice. Patients don’t always do well and often we have more work than we can accomplish. “Sadness of care can weigh on the team. We recognize that some patients drain your energy and we try to share this,” Dr. Hall said. The concept of workflow and swim lanes of responsibility is relevant here as well. Many of the teams I interviewed identified that all members need to know their role. Mr. Tetzlaff stated that we have to “balance the pool we swim in and share the lanes of responsibility.” With more demands for patient satisfaction and outcomes, the teams have additional stress. Dr. Rodriguez identified this when she stated, “We can’t do everything as individuals, and trust and delegation are critical. We must understand our limits but keep pushing each other toward excellence.” In my experience, hard work that is shared with others often leads to a change in perception. Knowing that others are there with you and challenged as much as you are can have a big impact.
While most teams did not articulate formal backup behaviors, most did mention the concept of using informal actions that provided backup. Recognizing that their team members may need help and how individuals can contribute was mentioned by each practice. Dr. Ramaekers said, “The team is important, like family. We notice it and it impacts us. Coverage of each other is critical; backup behaviors contribute to professional satisfaction, professional development, and mutual trust.” It makes sense that one facet of a team is being there to cover for and help each other. It’s not always recognized through formal systems, but people tend to respond positively to those who practice it. As Ms. Schriner stated, “I don’t feel like my day is done unless I check in with Ryan to see if I can ease his day.”
As I set out to explore burnout and the concept of team wellness, I knew that my own thoughts would influence how I had conversations with the various practices. I wanted to test the waters to see if others see teams through the same lens as myself. What surprised me was the level of thoughtfulness and depth with which people have considered team wellness.
Dr. Ramaekers seemed to view this through the lens of one’s professional self when he stated, “It’s important to frame your career to prevent burnout—you don’t want to create a miserable working environment.”
Others took a view based on personal responsibility, such as Ms. Peetz, who said, “My responsibility is to watch for burnout, set expectations, and check in with the team to see if they are doing okay.”
Others viewed team wellness through the lens of the health care environment. According to Dr. Rodriguez, “Work is not just about what happens in the clinic on any given day. There seems to be no limits on the expectations of patients and the hospitals for demands on the team.”
Finally, some viewed this through a more introspective lens. Mr. Mathai postulated that “faith and family are important, as well as working in teams at a respected institution—they can inspire us to do what it takes to live up to our reputation and our mission.”