The Doctor Dialogue

3.14.25

Happy Friday!

This week I am experimenting with opening up a discussion group on LinkedIn so people can see other subscribers' thoughts on my article (see button at bottom of newsletter). Please let me know if there are any technical difficulties. Without further ado, here is...

Teamwork in Medicine

Graduating with an MD or a DO is a license to kill, yet medicine is one of the only current professions that is centered around an oath–the Hippocratic Oath–whose charge is: Do No Harm. What is the key to doing no harm when the only reason people come to you is when they need help?

The answer lies in one simple word: teamwork.

So, what are the main drivers for teamwork in the medical field?

Medical Education

For Dr. Hugh Foy, a retired general surgeon who trained and spent most of his career at Harborview Medical Center in Seattle, the magic combination was long hours with high quality people.

“During my internship [in 1978], on our ER rotation, it was “24 on and 24 off.” We'd go in at 7 AM, and you'd walk out at 10:30 AM the next day having worked solid that whole time. On the General Surgery ward service it was even harder, “every other night call” meant you often worked 40 hours on, and 8 off. Fortunately, the rest of the one-month-at-a-time rotations were usually every third night call. So I mean, there's probably good laws where you can't run dogs and draft animals that hard. And not only were the hours long, it was intense.

After a grueling rotation in February, I had enough. I turned in a resignation letter effective at the end of the academic year in July. But the next rotation was on the Burn Unit, which was every 4th night call; a world of difference.

Moreover, the people that ran the [burn] unit were phenomenally talented and nice, kind, funny people. They treated their staff as colleagues, not as workers. So it was much more a very collegial atmosphere. So I went back to my program director's office and said, “do you mind if I stay?” And he said, “Not at all.” So I stayed; I stayed there for most of the rest of my career.”

The long hours Dr. Foy experienced during his internship are prohibited by the rules made by the organization that oversees residency training in the US, the Accreditation Council for Graduate Medical Education (ACGME). In 2003, the 80-hour work week was instated. In an effort to decrease burnout and increase quality of life, this policy cut the hours worked by residents and effectively reduced the patient care resident workforce in US teaching “safety net” hospitals by 33%.

Dr. Erika Goldstein, one of Dr. Foy’s colleagues, points out that saving physicians from this challenging work schedule had its downsides. The loss of the opportunity for deep, intense involvement for a resident in training in following the trajectory of a developing illness resulted in the loss of some important aspects of residency training.

“When you admitted somebody to the hospital when you were on service, they were very sick, and you were physically present for the first 36 hours of their illness, you really understood how and why things happened and how to prevent [mistakes], how to recognize them. You have to be there to see that.” In effect, studying the books could not replace being in the room where it happens.

However, Dr. Goldstein remembers a poignant conversation with her spouse: “when they went to the 80-hour work week, I remember saying to my husband, you know, tomorrow, they start the 80-hour work week. I don't know how we're going to fit in all the work and training with the scheduling changes. And he looked at me and he said, “you realize for us normal human beings, that's already 2 weeks' worth of work hours.” And I was like, “oh, yeah.” But deep down, I still think there were some incredible benefits to how residency training was structured [back then].”

One of the main benefits of long hours was medical educators, by sheer volume of experience, had a better chance to ensure residents accomplished competency in the necessary skills before completing their residency training. For a bit of background, after attending medical school for four years, doctors-in-training have to go through residency–the length of which depends on what specialty they declare. For example, general surgery requires a minimum of 5 years of rigorous education after medical school before one can practice. Internal medicine and pediatrics takes 3 years while neurosurgery can be up to 10 years.

As an internal medicine educator, Dr. Goldstein describes how the 80-hour work week changed the way she educated physicians-in-training: “I used to attend on the inpatient internal medicine service 3 months a year, in one month blocks three times a year. Over the years, faculty went from one month blocks to two week blocks which created additional challenges for residency training.

It made it more difficult to “diagnose” the skills of a 2nd year resident or to give meaningful feedback to a 3rd year resident who's about to graduate. How would you be able to give them guidance after only watching them for 2 weeks?” Other faculty expressed concerns surrounding loss of critical information about patients in each handoff between shifts, prevalence of a shift worker mentality that is not patient focused, and an overall decrease in the patient/doctor relationship.

The challenge then is to create the sense of camaraderie, trust, and mutual commitment while respecting the health of physicians and the time required of them at work. So what are the conditions which allow this sense of unity toward a common goal to arise? Everyone and their sister on the internet is selling the “best leadership class” for those looking to unlock their potential. The real question is framing this question for a team: how do we unlock our potential?

Even though Dr. Foy and Dr. Goldstein worked in the inpatient wards of a busy, inner city, “safety-net” hospital; the ethic of teamwork is important in all specialties. Put simply, there is no way for a doctor to get through their work day, no matter how long, without the help of the medical staff.

However, for many medical trainees, the intense competition in medical education–graded on a curve against classmates, moving on to a highly competitive residency position and perhaps a fellowship in a subspecialty – has the potential to instill in both the doctors and their patients a “savior” mentality.

Hero Worship

For Dr. Benjamin Danielson, a practicing pediatrician of more than 30 years, growing out of the “hero worship” mentality took time.

“Hero worship creates this idea that feeds on your ego as a young adult that you are going to come in and rescue people from deaths, that it's going to be your smarts alone that is going to save somebody.

Very cowboy, American, one against the world kind of mentality, and that is so damaging. And it takes you until you are at least in residency before you realize, “Wow, this is a team. Damn, that nurse is hella smarter than I am.”

I just got the best tip on how to take care of this patient from the cleaning person who just heard [the patient] talking about what they really need in order to get home. It's just such a team sport. It's built to be a team sport, yet training somehow convinces you that you're the sole star in it.”

To be a great doctor, you need confidence, not ego. Ego shatters with criticism and is unwilling to receive feedback while confidence is open to both.

This poses the question: In training, how does one learn to balance the pressure of calling the shots and not alienating the team you work with? Trying to make decisions in a Socratic fashion does not always work in medicine–decisions sometimes need to be made fast and without much resistance from the rest of the team.

This is why medical education is so rigorous and long; when you practice medicine, you are the head of a team which cares for people in their moments of need. Leadership in medicine needs to be rooted in two skills: 1) excellent medical and clinical expertise and 2) a deep understanding of how your team works best together. One without the other will not be enough.

The Casting Director

Dr. Carey Jackson, a retired general internist, understood how important people were and was intentional in the hiring process:

“I determined who I hired and how I hired. I didn't give that to somebody else. I knew that was what's important. It is like being a casting director for a movie or being a recruiting scout for a soccer team or a football team. Those are the people that are going to bring together the talent that's going to have magic or not have magic. So you can't give that to somebody else who just says, “we just need a body in that slot.”

And I remember hiring medical assistants who knew nothing. And at the same time, you could tell they cared. I used to tell the medical students, “I can teach you how to place a central line. I can't teach you to care. That's beyond me.” So I played an active role in who I brought into the clinic.

Why they were there and how we ran the clinic created a culture– in the clinic and interpreter services, community house calls, my research team, and other programs that I developed–so that there was a general sense of camaraderie and spirit of, “I don't know what's going on here, but we're in this together.”

We are in this together and we stand on the shoulders of giants. The team of today is built upon the excellence of the team yesterday. Yes, hero worship is generally an attitude to be avoided. However, some doctors do deserve the limelight.

Shoulders of Giants

For example, Dr. Alex Edwards highlights the reality that “in the last 100 years, we've gone from being able to treat nothing to being able to treat almost every disease you can think of and identifying many diseases that were previously unknown in one human lifetime. Antibiotics didn't come online until, for the civilian population, until late in World War 2. Should we have a little bit of a worship for Dr. Alexander Fleming who figured out antibiotics?

We probably should. That was an incredible discovery that changed the course of human history. You can't do modern medicine without antibiotics. You can't do surgery. You can't do cancer care. You can't have an ICU [intensive care unit] that functions without antibiotics.”

However, achieving the spotlight should not be the focus; providing excellent clinical care to patients through a well-functioning medical team should be the center of attention. Flowers, honors, and legacy will spring from excellence but it must be founded on the humble realization behind every wonderful doctor, there is a top-notch team. The trap of “It was my smarts alone” causes great harm to the patient, the doctor, and the medical staff.

Disposing of arrogance in trainees will be the greatest test of American medical education. The only way you can fulfill the Hippocratic oath of “Do No Harm” is to have the humility to say, “No matter how smart I am, I can’t do this alone.”

Next Week: Work/Life Balance in Medicine

Be well!

Your friend,

Ian Scott