Chapter 04: Building Teams by Building Culture and Developing Collaborative Leadership

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Chapter 04: Building Teams by Building Culture and Developing Collaborative Leadership

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In this chapter, Dr. Bruera talks about the lessons he learned about building teams at the Cross Cancer Institute, a model he brought to MD Anderson. He begins by describing the environment needed for a functioning team (a safe place where everyone has a voice and works for consensus) and uses the metaphor of a 'symphonic concert' to characterize the working relationship that results. Dr. Bruera then makes the connection to teams he has set up in the department at MD Anderson, saying that 'we depend on people referring patients to us' and this kind of team ensures the quality of care that brings in new patients. He notes that the department makes operational changes eight to ten times per year, assessing the results. He describes how the department plans and manages these change processes and gives several examples, including a 'failure' that required the department to return to a former procedure. Next, Dr. Bruera talks about the stresses of palliative care and the support the department has created to address this. He shows two informative handbooks on self-care distributed to all department members. Dr. Bruera then talks about his view that burnout and stress are linked to the 'superstar model' of how resources and prestige are assigned in departments. He says that too much of medicine is geared toward supporting the individual. He talks about how Palliative Care balances expectations among the faculty to establish a more equitable and less ego-centered culture more geared to team work. He discusses how he has shaped his own persona as a leader to role-model this mentality.

Identifier

BrueraE_01_20180806_C04

Publication Date

8-6-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Overview; Leadership; On Leadership; Professional Practice; The Professional at Work; MD Anderson Culture; Working Environment; Collaborations; Professional Values, Ethics, Purpose; The Researcher

Transcript

Tacey A. Rosolowsi, PhD:

Absolutely. Now, what were some of the kind of—I don’t know if lessons is the right way to say it, but were there certain principles or guidelines that you learned about setting up teams, these multi-practice teams, or maybe I should say multi-specialty teams. What were the high points or key points from that?

Eduardo Bruera, MD:

I think to me, it was extremely important to do what I learned from my dad and from Neil and from my experience in soccer, and other experiences, that was to really work as a team, everybody needs to feel safe and everybody has to have a voice. We need to try to vote on most of the things, we need to try to get consensus if possible, meaning by that, 80 percent agreeing on anything that we do, and we need to operate as a collaborative, and that collaborative needs all of us to relinquish positions. We need to operate as a group, as a team, and all my life we operated as team practice. At Anderson, for the last nineteen years, we always have operated as a team practice, and that means that I don’t make decisions, we make decisions. What I do is I go there and fight, and I fight harder with my bosses when I know I am not there representing my own views, but the views of a lot of people working together, who have reached the conclusion that this is the way we have to do it. I think we learned, I learned, and all of us I think applied, the importance of team practice, as compared the more pyramidal CEO-based system.

Tacey A. Rosolowsi, PhD:

Right. What are some ways that you have discovered to overcome those gaps that can happen between specializations, gaps in jargon, gaps in fundamental concerns, gaps in those kinds of—and gaps in workflow and perspective, I mean those sort of nitty-gritty. How do you help teams overcome those differences so they can move towards consensus and safety?

Eduardo Bruera, MD:

We try to operate with a joint team approach, meaning by that, we operate like a symphonic orchestra, that’s because we sound better as a team than any soloist. If anybody goes to hear the violin playing a lot, it might Itzhak Perlman but you’re still going to be bored after forty minutes. But if you hear a symphony orchestra, you know that what they can do is something that the best violinist in the world cannot get through. And so we know that we need to complement each other to be harmonious. You’re going to be dissonant, because if you decide to play your own way, you are not only not going to sound well, but you’re going to hurt the sound of everybody else. So we do understand that we need to modify our clinical practices in consensus so that you’re identifying those important gaps and you’re identifying the importance of referring people --would depend forever, on people sending us their patients. Nobody comes from the street, to MD Anderson, saying, I want to get supportive care, I want to get palliative care. They come because they want to make their cancer history, so we depend on other clinicians saying this team is wonderful, we need them. We do not have an ownership of a body of knowledge that makes us unique. If you have a melanoma, you go to melanoma, if you have breast cancer, you go to breast. Those people receive the patients and that’s it. We never receive anyone and therefore, we are an elective option, so we need to make ourselves highly desired by all those colleagues, as someone who can make their patients’ lives better and their own lives better. The way we do it is by making sure that each time they call a member of our team, they get a product that is of similar quality. So we need to internalize in ourselves: that we need to change together by incorporating new treatments, by dropping other treatments. We need to operate as one symphonic orchestra. Then this has been as part of the way we’ve tried to convey to each other the importance of this, and that is done with the safety of being able to say, I found a new medicine, why don’t we start using that one, or I believe that the way we’re measuring the symptoms so far is not that good, let’s change it. And then bring the evidence and discuss it, and then adopt it, and then change things. And we do change things about eight or ten times a year. About eight or ten times a year, we change the way we operate, but we do it in such a way that we all meet, we all discuss it, we all have the possibility to vet things, and whenever we change things, we change them for a period of two to three months. We never change things definitely. Everything is changed for a period of two to three months, during which we observe how it’s working and if it’s not working, nobody lost face, it was worthwhile, let’s go back to the way we were doing it before. We’ve done it many times. We did it in a certain way for a few months, it didn’t work, we go back.

Tacey A. Rosolowsi, PhD:

Can you give me an example?

Eduardo Bruera, MD:

For example, we adopt sometimes, a new way of giving medications that we believe is going to shorten the time for pain control. But sometimes those medications are either not always available, or they take too long to come from the pharmacy, or the patients don’t like them, and then we say, well that system is not effective, let’s go back to the way we were doing it. Other times, we have a system in which we are operating in our mobile teams, seeing patients in the floors, and when we find a patient who needs to be transferred to the Palliative Care Unit, we transfer the patient, but we find that if you’re going to transfer that patient, it will take you forty-five minutes extra work. So you get punished for doing the right thing and then, what we identify is that if you find a second team whose job is to transfer patients. Now, that second team gets notified by you and you go ahead and do your work, and that team will come with the specific goal of organizing transfer for the day, and so, of course it takes a lot of coordination to do that. Another thing is sometimes we have two, three, four patients in the clinic, and we have two or three, four doctors being called to see those patients, and we learned quickly that when we asked two hundred—because we do that, most of that we do it in research based. So we asked more than two hundred patients the following question: Sir, would you like to be seen today, even though you might be seen by another doctor, or would you like to come tomorrow and see Dr. Bruera? Eighty five percent of them said no, I’d like to be seen today by whoever, because if I have to come tomorrow, I have to drive again, I have to pay fifteen dollars parking, and on top of that, I’m not feeling very well today. So if you can guarantee to me that the person who is going to see me will operate in a similar way as Dr. Bruera, I prefer to be seen today. So we went from a doctor-based clinic to a team-based clinic. So we emphasized access more than continuity, with the understanding that if somebody is really interested in seeing Dr. Bruera, they can always come on Thursday and see Dr. Bruera, but if they want to be seen rapidly, they will see one of the colleagues. Our satisfaction rates have consistently been the highest at MD Anderson, even though our patients are very, very ill. And the reason for that is that we try to adapt to what we thought the patients’ experiences were at MD Anderson. Of course that could not easily be done by another primary team, because they might want to see the oncologist for decisions, but when they’re not feeling well, they want to be seen by someone today, rather than in three days, five days, six days. All those changes in the way we operate took, first to observe, then to decide what could we do different, then try to get consensus by all the players, you know this is not the way we’ve been doing it, but I am willing to give it a try and see what happens. I am not so sure about this. And then say well, okay, let’s try it for two months and then we’ll come back. Putting music in our center, in our Palliative Care Unit, was regarded as really bad by our own faculty and some of our nurses. They said, my goodness, we’re going to make mistakes here, we’re going to get distracted, we’re going to write the wrong orders, and the patients might not like it, and the families might not like it. So we basically had to do it again three months later, an anonymous survey, and I always emphasize anonymity because it’s not easy for an assistant professor to vote against Bruera, because I happen to be the professor, I’m the chief. So we emphasize a lot of anonymity, in which people will vote to one of our research assistants, for yes or no. Although there was very, very heated arguments against, when we asked patients and families and staff members, the negativity went down from about 60 to 70 percent openly, to 9 percent in the anonymous. Everybody loved the music and then we kept the music. But putting the music was a shock. Abolishing the waiting room was another thing that we wanted to do and again, the waiting room to us is not good, because you have people who are suffering. Especially in palliative care, having a lot of people who are suffering sitting in front of each other, they don’t look good. It required us to reengineer the patient floor, and a lot of our doctors said and our nurses said, my goodness, this is going to be crazy, because I’m going to have all my rooms full, and how am I going to flow the patients, and how are we going to keep the appointments and how are we going to keep those rooms open? We had to put big boards with all the names of the patients, and the rooms, like if it was an emergency room, to see which room was open and which room was not open. Instead of having three rooms per doctor, we had every room for every doctor, and we had to reengineer things. Again, it took thinking, can we do it differently? Yes. Okay, well, convincing some people, being reluctant, and then ask them, and they overwhelmingly loved it. So we’ve introduced over time, a lot of changes. But we require building consensus, and then evaluating, and then some of them were failures. We embedded a doctor into the Thoracic Medical Oncology Clinic, to do palliative care there, to get the first patients and then move them later on, to the Supportive Care Center; it was a failure. It did not have the resources, it did not have the numbers of patients, and so on. We did that for three or four months, five months, and then we went back and said it didn’t work, let’s move back. And I think when people know that it’s going to be for a time period and then if it doesn’t work we go back, they have a trend to say let’s give it a try.

Tacey A. Rosolowsi, PhD:

Right. Well, it’s the trust thing: it isn’t going to be forever, it’s not a top down, this is the way it is, suck it up kind of thing.

Eduardo Bruera, MD:

Yeah, exactly. We all made the decision together, we all agreed, there was consensus, and now we’ll move on. We do the same thing with anonymous surveys about workload. Are you finding that the workload is too bad for you? I’ve always felt that it was extremely important for the patients and families, that they are seeing a doctor who is confident, comfortable within their own job, within their own skin, and that they’re comfortable with their working conditions. So we implemented measures for self-care, that actually everybody carries them in our department. I personally feel very nice, but this is what everybody cares here, about what you are supposed to do. You are supposed to take a nap. You’re supposed to drink a lot of water. You are supposed to take some time out and listen to music. You are supposed to ask for help, you are supposed to eat, and you’re supposed to debrief when you have a bad case.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

In our interdepartmental guidelines, that have all the things that we’re supposed to do, we have one that is it a weekly self-care checklist that tells you things that you can achieve to take care of yourself. This is on work and this is on your week self-care. [Contact the Research Medical Library for copies of these materials.]

Tacey A. Rosolowsi, PhD:

Wow. Would you have copies of this, because I can put things into your transcript or connect them to your interview, so people could see that.

Eduardo Bruera, MD:

Oh yes, absolutely, we can give you those.

Tacey A. Rosolowsi, PhD:

Yeah, that would be great, yeah I’ll make a note about that.

Eduardo Bruera, MD:

I know our faculty and our staff have these, so we have the feeling that if you create an environment where people feel safe to say things, to raise things, feel comfortable and reasonably supported, then they’re more likely to go there and do a better job. I think they’re also going to do a good job for an institution, with everybody who comes to see us.

Tacey A. Rosolowsi, PhD:

Well, I’m really struck too, I mean I did some work connected up with the burnout symposium last year, and one of the things that came out over and over is how the traditional culture of medicine is basically designed to put people into a state of burnout, because it’s always work alone, never admit you need any help, you have to do more and more and more and never complain because you’re a super-person. All those things that basically set people up.

Eduardo Bruera, MD:

Yes.

Tacey A. Rosolowsi, PhD:

And by creating handbooks like this, in a culture in which it’s expected, I mean you’re creating a culture in which it’s okay for people to say, wait a minute, dealing with a tough case, that is tough and I may need to speak with someone, that’s part of community building. So I mean you’re shifting the culture, in at least this corner of the institution.

Eduardo Bruera, MD:

Yes, you’re absolutely right, that’s what we perceived. We see dying people all the time, so our practice is particularly stressful, because we don’t have those balances between the patient that you are seeing who is doing bad, and then three patients that are doing good, and then a couple who are cured. We don’t see those that are cured or are doing well, we see the ones that are doing bad, so for us it’s particularly important that we take care of the team. So I personally --probably because of my years as a coach-- I always made the point that I was not there to support the stars. Too much of medicine has been wrongly construed on support the superstar and the rest should do the scud work and should not be treated well. That is not very smart because the overwhelming majority of the work is done by the ones who do the scud work. So by emphasizing that superstar and having them only do clinical care one day a week, and giving them all the research time and all the glory and all the papers, all you are creating is resentment by a lot of the other people that are having to do the clinical work. It happens to be that the clinical work is done by those people that you do not particularly respect. So we created exactly the opposite: that is an emphasis on the importance of the people who see the patients every day. And then there are some people who will do less number of days of clinic a week, because they will bring grants and so on, but there’s nothing among those individuals that will be more meritorious or different than the rest. In fact, I take call and come on weekends exactly the same as any other clinical faculty that is 80 percent clinical, and so all my tenured faculty have to do exactly the same amount, because if I am doing this at sixty-three, then it’s understood that the younger tenured professors should be coming here and doing clinical call. That’s a message to everybody: that we all have to keep a low profile, be involved in helping each other, and that ultimately, it’s about the patients. That helps break some of that barrier between the so-called superstar and the rest, that I think is, my impression is that leads a lot to burnout. So in my soccer times, if you came for practice, you would get your playing time and ultimately, if you look at happiness as an outcome, we were the happiest team of all. And happiest means happiness by all the players, not happiness by one player and unhappiness by the rest.

Tacey A. Rosolowsi, PhD:

Right, right. I’m thinking too, I mean the superstar model is very much, there are only particular types of achievement or a particular type of personal talent that we respect and reward. But just because somebody’s really great at giving grants, doesn’t mean that they’re very good at sitting down and listening and diagnosing the question behind the question, and a person that’s got an emotional issue at work. This is a model that really balances and acknowledges that people bring a whole array of abilities to a team. Very, very interesting.

Eduardo Bruera, MD:

And you know, we have been finding that the productivity of our team is one of the largest in the institution, even though we have much less tenured positions, much less protected time. If you look by a citation index and our H-index and our publication record, it’s very, very high. That means that you do not need the superstars to do very good work. A whole bunch of mediocre people helping each other can do extraordinary things. You can have all these people helping each other and publishing and publishing in the best journals and doing a lot of work, because it’s not that you need extraordinary achievements. If we all pitch in, at the end of the year, we’ve done good academic work. So, I personally do not agree with a model of having a superstar and giving that person everything, and then the rest working, because I think burnout, to a great degree, is linked to that model of medicine. To me, it’s the collective governance, that really works, but it requires that we assume that we’re going to behave in that way. That means I need to swallow a lot of my pride about the way I think things should be done, and be patient, and sometimes know that no, I’m not going to be able to do this, we’re going to have to wait two more weeks, during the faculty meetings happens, until the staff meeting happens. We need to be patient because by decree, I can make this happen tomorrow. But I’m going to hurt a lot of people’s morale if I do it. So the patients and the bringing it for everybody to discuss and listening to the arguments of those who are not in favor and making all the necessary modifications, I think that’s something that sometimes it is felt as not productive. People perceive that that is not productive. I think it’s a bad concept, because it’s productive in building a team.

Tacey A. Rosolowsi, PhD:

Absolutely. Well it’s not the traditional model of leadership, you know the lone leader that makes the decree, as you said, and then we move on. It’s a different model, it’s collaborative leadership.

Eduardo Bruera, MD:

Yes, that’s our—I think our understanding is that that’s what we do, and that we bring somebody in here and I don’t remember having ever appointed anyone alone. A hundred percent of the appointments that we’ve always made here, have been collective appointments. I make a point that that’s the way we operate in our team and that is very important, because if you had a role in bringing someone to the team, then you are going to be vested in the success of this person. You’re going to be welcoming them and trying to make them feel good and support them. While if you’ve got somebody who parachuted next door to you and says hi, I’m coming here to work as of today, you’re going to be puzzled and you’re not necessarily going to be that welcoming. So we find that even for the new person that is coming, it is so important to be welcomed by consensus.

Tacey A. Rosolowsi, PhD:

Well, and a collective interview and selection process also builds bridges with that new person coming in, so there’s a basis for conversation afterwards. It’s not like they’re parachuting onto an island.

Eduardo Bruera, MD:

Exactly, exactly.

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Chapter 04: Building Teams by Building Culture and Developing Collaborative Leadership

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