0:00:12.150,0:00:17.600 >> Good evening everyone. 0:00:17.600,0:00:21.650 I am a Communications Researcher and I study healthcare teams, 0:00:21.650,0:00:24.890 that means I follow them around while they do their work, 0:00:24.890,0:00:29.735 and I talk to them afterwards about why it is that they work the way they do. 0:00:29.735,0:00:34.850 I've studied teams in all kinds of healthcare settings; operating rooms, 0:00:34.850,0:00:37.760 intensive care units, emergency departments, 0:00:37.760,0:00:42.440 pediatric hospitals, rehab hospitals, transplant units. 0:00:42.440,0:00:44.250 Whenever I study a team, 0:00:44.250,0:00:45.900 I ask three questions. 0:00:45.900,0:00:48.615 How does this team communicate? 0:00:48.615,0:00:53.800 How does their communication influence the patient care they can deliver? 0:00:53.800,0:00:57.739 How would we educate healthcare professionals and students, 0:00:57.739,0:01:02.800 so that their team communication and their patient care improve? 0:01:02.800,0:01:07.030 I've been studying healthcare teams for about 15 years, 0:01:07.030,0:01:11.570 and one of the most important things I've learned to date is this. 0:01:11.570,0:01:20.379 Healthcare is full of highly competent individuals, competent family physicians, 0:01:20.379,0:01:25.580 competent nurses and nurse practitioners, competent specialists, 0:01:25.580,0:01:32.550 competent pharmacists, dietitians, home-care workers, social workers. 0:01:32.800,0:01:40.220 But only sometimes do these competent individuals come together to form a competent team. 0:01:40.220,0:01:43.035 In fact, not infrequently, 0:01:43.035,0:01:48.620 competent individuals come together to form an incompetent team. 0:01:49.790,0:01:52.020 You might be wondering, 0:01:52.020,0:01:54.490 how is that possible? 0:01:54.530,0:01:57.480 Well, let me tell you a story. 0:01:57.480,0:02:05.050 This is Joe, he's 75 years old and he lives at home alone since his wife died a year ago. 0:02:05.050,0:02:07.780 Joe had his first heart attack at 55, 0:02:07.780,0:02:09.685 and he has had three more since. 0:02:09.685,0:02:12.700 He's been a diabetic for 25 years and 0:02:12.700,0:02:16.340 because of his diabetes he has some mild kidney trouble. 0:02:16.350,0:02:20.725 A month ago, Joe was admitted to hospital for pneumonia, 0:02:20.725,0:02:22.720 and while he was in hospital, 0:02:22.720,0:02:24.470 his kidney troubles worsened due to 0:02:24.470,0:02:28.085 a drug side effect from one of his blood pressure pills. 0:02:28.085,0:02:32.540 The hospital doctors stopped this pill and Joe did well, 0:02:32.540,0:02:35.970 recovered from his pneumonia and went home. 0:02:36.580,0:02:39.245 About a week after he went home, 0:02:39.245,0:02:42.125 he had a follow-up appointment with his family doctor, 0:02:42.125,0:02:44.600 but the discharge note hadn't made it to 0:02:44.600,0:02:47.225 the family doctor's office yet from the hospital. 0:02:47.225,0:02:51.750 So, the doctor doesn't know about his kidney trouble in hospital, 0:02:51.750,0:02:54.440 Joe doesn't have any medication list to bring with 0:02:54.440,0:02:56.960 him but he does bring all of his pill bottles 0:02:56.960,0:02:58.970 including the pill that was stopped in 0:02:58.970,0:03:02.045 hospital because Joe restarted it when he got home, 0:03:02.045,0:03:04.465 he didn't know he wasn't supposed to. 0:03:04.465,0:03:07.750 The family doctor is looking at the blood test results 0:03:07.750,0:03:10.479 from about six weeks before Joe went into hospital, 0:03:10.479,0:03:13.525 and she's concerned about his blood sugar control. 0:03:13.525,0:03:18.650 So, she refers him to a diabetes specialist who he has seen in the past. 0:03:19.230,0:03:22.945 But two weeks later when Joe goes to this appointment, 0:03:22.945,0:03:28.090 the diabetes specialist shares the family doctor's concern about the blood sugar control, 0:03:28.090,0:03:32.530 and he decides that Joe's current medication must not be working well enough. 0:03:32.530,0:03:36.700 So he prescribes a new blood sugar control medication. 0:03:36.700,0:03:39.820 On his way home from that specialist appointment, 0:03:39.820,0:03:44.870 Joe pulls into a pharmacy he doesn't usually go to and he fills this new prescription. 0:03:45.740,0:03:48.740 Now, for the last number of months Joe has been 0:03:48.740,0:03:51.365 having homecare nurses come visit him in his home, 0:03:51.365,0:03:56.060 and one of the things they'd become concerned about is his medication compliances. 0:03:56.060,0:03:59.125 You see sometimes Joe forgets to take his pills, 0:03:59.125,0:04:01.100 sometimes when Joe remembers, 0:04:01.100,0:04:04.355 he doubles the dose to make up for not taking them. 0:04:04.355,0:04:07.700 Now the nurses are working with Joe and they're teaching him 0:04:07.700,0:04:10.790 new medication management strategies to deal with this problem, 0:04:10.790,0:04:14.270 and they're recording the problem in the home care binder. 0:04:14.270,0:04:16.640 But the family doctor doesn't know about it 0:04:16.640,0:04:20.170 nor is communicated to the diabetes specialist. 0:04:20.959,0:04:23.060 Now as it happens, 0:04:23.060,0:04:27.150 the new medication that the specialists prescribed is a little hard on the kidneys, 0:04:27.150,0:04:29.990 and the specialist wouldn't have prescribed it if he'd 0:04:29.990,0:04:33.840 known of Joe's recent kidney trouble in hospital. 0:04:33.880,0:04:38.270 But he didn't know, and Joe shows 0:04:38.270,0:04:41.989 up in the emergency room couple days after starting his new prescription, 0:04:41.989,0:04:44.790 with a low blood sugar reaction. 0:04:44.810,0:04:48.430 Does any on these sound familiar? 0:04:50.090,0:04:53.055 What's going on here? 0:04:53.055,0:04:55.695 Joe got competent care in hospital, 0:04:55.695,0:04:57.420 he recovered from his pneumonia. 0:04:57.420,0:05:00.110 He got competent care from his family doctor, 0:05:00.110,0:05:03.560 his diabetes specialist, his homecare nurses, and the pharmacist, 0:05:03.560,0:05:06.440 each of those individuals within their scope of 0:05:06.440,0:05:09.590 practice and acting on the information at hand, 0:05:09.590,0:05:11.665 did the right thing for Joe, 0:05:11.665,0:05:18.930 but the sum total of those care events is not overall competent care for Joe. 0:05:19.780,0:05:23.270 Now this is a very complex problem 0:05:23.270,0:05:26.150 and it's being tackled from a number of different angles, 0:05:26.150,0:05:30.259 systems engineers are trying to understand it better to improve the situation, 0:05:30.259,0:05:32.630 organizational scientists are trying to work on it, 0:05:32.630,0:05:34.405 sociologists are working on it. 0:05:34.405,0:05:38.630 Tonight, I'm going to shed some light on this problem from my perspective as 0:05:38.630,0:05:43.770 a communications researcher who's interested in improving medical education. 0:05:45.280,0:05:49.700 There are significant barriers that make it difficult for 0:05:49.700,0:05:53.959 individual competence to translate into collective competence, 0:05:53.959,0:05:56.700 I'm going to focus on three. 0:05:56.720,0:06:00.240 The first is scientific reductionism, 0:06:00.240,0:06:02.600 this refers to the way that we tackle 0:06:02.600,0:06:08.030 complex scientific phenomena by breaking them down into their component parts. 0:06:08.030,0:06:10.520 Now scientific reductionism has produced 0:06:10.520,0:06:14.980 some spectacular advances in our knowledge but translated into patient care, 0:06:14.980,0:06:18.110 it means that Joe's heart disease, his diabetes, 0:06:18.110,0:06:22.620 and his kidney troubles are all treated as separate entities. 0:06:22.840,0:06:29.345 The separate barrier between individual and collective competence is specialization. 0:06:29.345,0:06:32.225 Now medical specialization is necessary, 0:06:32.225,0:06:35.180 no physician can know everything there is to know about 0:06:35.180,0:06:38.925 medicine but specialization has consequences. 0:06:38.925,0:06:42.270 If I have heart disease, ovarian cancer, 0:06:42.270,0:06:48.005 and depression, all three of those issues will be treated by three different specialists. 0:06:48.005,0:06:50.260 If I live in a rural area, 0:06:50.260,0:06:55.100 those three specialists will likely work for three distinct healthcare organizations, 0:06:55.100,0:07:00.540 which will likely be located in three different cities. 0:07:01.550,0:07:04.385 The third barrier between 0:07:04.385,0:07:10.925 individual and collective competence is the very concept of individual competence itself. 0:07:10.925,0:07:12.860 The goal of producing 0:07:12.860,0:07:15.920 an individually competent healthcare provider with 0:07:15.920,0:07:20.140 their own specific tightly bounded expertise, 0:07:20.140,0:07:22.490 drives everything in health professions 0:07:22.490,0:07:26.490 education generally and medical education specifically. 0:07:26.720,0:07:30.795 Now each of these three things: reductionism, 0:07:30.795,0:07:36.170 specialization, and the goal of individual competence are in and of themselves good. 0:07:36.170,0:07:40.195 Reductionism allows us to understand complex problems, 0:07:40.195,0:07:45.540 specialization allows us to build a deep expertise in a particular area, 0:07:45.540,0:07:48.050 and individual competence well everybody 0:07:48.050,0:07:51.315 wants an individually competent healthcare provider right? 0:07:51.315,0:07:55.060 But together and kind of paradoxically, 0:07:55.060,0:08:00.820 these three factors combine to produce one of healthcare's greatest weaknesses. 0:08:00.820,0:08:05.465 That is the providers work in isolation from one another, 0:08:05.465,0:08:11.095 each person focused on the particular issue about which they are an expert. 0:08:11.095,0:08:14.630 When that happens, patients can fall into 0:08:14.630,0:08:19.500 the cracks between individually competent care providers. 0:08:20.910,0:08:23.290 The theme of tonight's event in 0:08:23.290,0:08:27.715 adaptation and one way of expressing the meaning of adaptation 0:08:27.715,0:08:30.655 is that it's a process of change by which an organism 0:08:30.655,0:08:34.480 or a species becomes better suited to its environment. 0:08:34.480,0:08:37.914 I'm suggesting tonight that we need to adapt 0:08:37.914,0:08:42.380 our thinking so that we can provide better patient care. 0:08:42.720,0:08:46.570 What do we need to adapt from? 0:08:46.570,0:08:49.885 Well, I would argue that we need to adapt from 0:08:49.885,0:08:54.580 our exclusive focus on the goal of individual competence. 0:08:54.580,0:08:59.590 Individual competence is a set of pervasive and rarely challenged assumptions. 0:08:59.590,0:09:01.690 It's not unique to medical education, 0:09:01.690,0:09:04.255 it's true of education everywhere. 0:09:04.255,0:09:08.470 Three of these assumptions are very important to my argument tonight. 0:09:08.470,0:09:12.700 One is the premise that competency is a quality the individuals possess. 0:09:12.700,0:09:14.590 So, I'm competent because of, 0:09:14.590,0:09:17.935 for instance, the knowledge I possess in my head. 0:09:17.935,0:09:21.400 Related to this is the premise that competence is 0:09:21.400,0:09:24.984 a state to be achieved so that we can take naive learners, 0:09:24.984,0:09:27.520 put them through a medical education process, 0:09:27.520,0:09:33.835 fill their empty vessels up with competence and graduate them in a state of competence. 0:09:33.835,0:09:36.820 Related to this is the third premise, 0:09:36.820,0:09:39.925 which is that, competence is context-free. 0:09:39.925,0:09:42.790 Its independent of time and space. 0:09:42.790,0:09:45.640 So, if I'm competent tonight in Bayfield, 0:09:45.640,0:09:50.245 I'll be competent next week in Toronto and next year in Paris, France. 0:09:50.245,0:09:56.050 Now, this notion of individual competence drives everything in medical education, 0:09:56.050,0:09:59.530 from the way we select candidates for entry into medical school, 0:09:59.530,0:10:02.245 to the way that we teach and assess their performance, 0:10:02.245,0:10:05.035 to the way that we license them for practice, 0:10:05.035,0:10:09.910 monitor their practice over the course of their career and if we smell a problem, 0:10:09.910,0:10:12.745 we look for the individual most responsible, 0:10:12.745,0:10:14.784 we pull them out of the system, 0:10:14.784,0:10:17.890 remediate them if necessary and put them back in. 0:10:17.890,0:10:21.080 Individual competence everywhere. 0:10:21.570,0:10:28.285 Now, this educational model made sense in the environment which created it, 0:10:28.285,0:10:32.395 and that healthcare environment was this; 0:10:32.395,0:10:39.920 a single patient visiting their physician for the care of an ailment. 0:10:40.980,0:10:44.395 The healthcare environment has changed. 0:10:44.395,0:10:49.210 This is a report published in 2011 by the Canadian Institute of Health Information. 0:10:49.210,0:10:50.950 You can find it online. 0:10:50.950,0:10:56.215 In a nutshell, what it tells us is that Joe is an average patient. 0:10:56.215,0:11:01.165 A quarter of Canadian seniors report having three or more chronic conditions. 0:11:01.165,0:11:03.160 That's about a million people. 0:11:03.160,0:11:09.290 These same people report over 13 million healthcare visits per year. 0:11:09.540,0:11:12.940 We're no longer talking about patients going to 0:11:12.940,0:11:16.105 see their single physician with a single ailment. 0:11:16.105,0:11:18.565 The environment has radically changed, 0:11:18.565,0:11:22.180 but the way we think about competence has not. 0:11:22.180,0:11:26.000 So, what do we need to adapt to? 0:11:26.880,0:11:33.955 We need to broaden our notion of competence to include collective competence. 0:11:33.955,0:11:36.250 What do I mean by that? 0:11:36.250,0:11:41.785 Collective competence is a distributed capacity of a system. 0:11:41.785,0:11:45.250 It's not reducible to a single individual. 0:11:45.250,0:11:49.045 Collective competence is also an evolving dynamic. 0:11:49.045,0:11:52.450 It's not a stable trait, it changes. 0:11:52.450,0:11:55.330 It changes in relation to context. 0:11:55.330,0:11:57.940 It is intimately tied to context. 0:11:57.940,0:12:01.930 The competence of my performance is influenced by 0:12:01.930,0:12:07.730 the limitations and the affordances of the situation that I'm in at this moment. 0:12:08.880,0:12:14.410 I'm talking about an enormous adaptation, a game changer. 0:12:14.410,0:12:17.695 For hundreds of years in Madison we've thought about 0:12:17.695,0:12:20.170 individual competence and I'm talking about 0:12:20.170,0:12:24.190 changing that notion to include something very different. 0:12:24.190,0:12:27.860 You might wonder, is this even possible? 0:12:28.440,0:12:33.280 Not only is it possible but I'd like to touch on three ways in 0:12:33.280,0:12:38.110 which we are right now moving towards collective competence. 0:12:38.110,0:12:41.363 The first, I think, is a relatively simple way. 0:12:41.363,0:12:43.255 Let's go back to Joe. 0:12:43.255,0:12:48.130 The fundamental problem at the crux of Joe's situation is this. 0:12:48.130,0:12:53.920 Joe travels through the healthcare system more quickly than his health information does. 0:12:53.920,0:12:58.210 We have the technology to address this problem, 0:12:58.210,0:13:00.535 to move information more efficiently. 0:13:00.535,0:13:06.535 One example of relevance to Joe's story is the global medication electronic record. 0:13:06.535,0:13:10.260 This would have allowed the pharmacist that Joe went to, 0:13:10.260,0:13:13.380 to view the prescription in light of all of 0:13:13.380,0:13:16.710 Joe's current medications and his past medications. 0:13:16.710,0:13:19.695 Unfortunately, the pharmacist in Joe's jurisdiction 0:13:19.695,0:13:23.060 didn't have access to a global medication electronic record. 0:13:23.060,0:13:25.850 But many jurisdictions do. 0:13:26.480,0:13:31.230 A more sophisticated way in which we're moving towards collective competence right 0:13:31.230,0:13:35.840 now is an experiment that we're all involved in in this room. 0:13:35.840,0:13:40.960 That's the shift to deliver primary care through family health teams. 0:13:40.960,0:13:45.550 A family health team brings together a primary care physician, 0:13:45.550,0:13:51.850 a primary care nurses and a number of other health professionals: pharmacists, 0:13:51.850,0:13:55.840 social workers, dietitians, physical therapists, et cetera. 0:13:55.840,0:14:00.145 It puts them all under one roof so that Joe 0:14:00.145,0:14:05.990 doesn't have to go off to six different places to have six different needs met. 0:14:06.750,0:14:13.585 Family healthcare teams offer a better model for teamwork and collective competence. 0:14:13.585,0:14:17.650 They also come with new funding mechanisms that ought to promote 0:14:17.650,0:14:22.580 collective competence in a way that the traditional funding mechanisms never could. 0:14:24.390,0:14:30.745 But it takes more than putting people under one roof to get to collective competence. 0:14:30.745,0:14:34.720 Listen to these pharmacists from a new family health team. 0:14:34.720,0:14:39.130 "I'm a pharmacist, so I know how to be a pharmacist. 0:14:39.130,0:14:41.110 I don't know how to be a pharmacist in 0:14:41.110,0:14:44.365 a family health team because nobody knows about that yet. 0:14:44.365,0:14:48.550 I walked in and I did pharmacy things but I didn't know what 0:14:48.550,0:14:52.915 that meant in relation to what the nurse does or what the dietitian does." 0:14:52.915,0:14:54.850 This pharmacist is saying, 0:14:54.850,0:15:01.015 I'm individually competent but I'm not so sure about how to be collectively competent. 0:15:01.015,0:15:04.360 The structural change involved in family health teams is 0:15:04.360,0:15:07.795 an enormously positive first step but it's insufficient. 0:15:07.795,0:15:11.660 We need an educational change to go along with it. 0:15:13.110,0:15:17.200 The third way in which we're moving towards collective competence is 0:15:17.200,0:15:20.905 a more strategic way and I've picked one of many examples here. 0:15:20.905,0:15:23.455 By strategic, I mean, 0:15:23.455,0:15:25.690 take a look at the healthcare system, 0:15:25.690,0:15:30.130 find those points in the system where a failure of collective competence can have 0:15:30.130,0:15:32.410 dire consequences and build 0:15:32.410,0:15:36.595 initiatives to support collective competence in those moments. 0:15:36.595,0:15:40.090 What I'm going to talk about is an initiative to build 0:15:40.090,0:15:44.770 collective competence in the operating room to help surgical teams communicate better. 0:15:44.770,0:15:47.440 This is an initiative that my research team and others 0:15:47.440,0:15:50.530 around the world have had intimate involvement with. 0:15:50.530,0:15:55.480 Now, why pick the operating room as a moment in the healthcare system? 0:15:55.480,0:16:01.000 Well, when they analyze errors in the operating room such as wrong site surgery, 0:16:01.000,0:16:04.750 they find that the root cause is far more likely to be a breakdown in 0:16:04.750,0:16:09.950 communication on the team than it is technical skill or a lack of knowledge. 0:16:10.260,0:16:13.810 So, a number of us around the world conducted research, 0:16:13.810,0:16:15.430 myself for about a decade, 0:16:15.430,0:16:19.525 in operating rooms trying to figure out how could we help this situation. 0:16:19.525,0:16:22.345 What arose from that international research 0:16:22.345,0:16:25.690 was what's called by the World Health Organization now, 0:16:25.690,0:16:28.345 the Safe Surgery Saves Lives initiative. 0:16:28.345,0:16:33.610 What it is, is a protocol for surgeon and their citizens and nurse to come together at 0:16:33.610,0:16:36.190 points in a surgical procedure and make sure 0:16:36.190,0:16:39.805 they're sharing the critically salient information. 0:16:39.805,0:16:42.950 This initiative has in fact become so 0:16:42.950,0:16:46.055 successful that it's had enormous international uptake. 0:16:46.055,0:16:50.690 You can go to the WHO website and actually zoom in on your own jurisdiction. 0:16:50.690,0:16:53.580 I tested it. I zoomed in on us here. 0:16:53.580,0:16:59.205 You can see the hospitals that are registered in this particular checklist initiative. 0:16:59.205,0:17:04.310 In fact, it's become mandatory in this country and many others for 0:17:04.310,0:17:06.710 surgical teams to do some kind of 0:17:06.710,0:17:10.980 preoperative briefing or checklist before they start an operation. 0:17:12.270,0:17:17.630 I've described to you three advances that I think are important ones 0:17:17.630,0:17:19.790 and show the potential and the work on 0:17:19.790,0:17:23.315 the ground to move towards collective competence now. 0:17:23.315,0:17:28.369 But collective competence is about more than good software, 0:17:28.369,0:17:32.195 good Internet use, checklists, other tools. 0:17:32.195,0:17:36.290 Collective competence must be a value and 0:17:36.290,0:17:40.905 underpinning philosophy and an educational mission. 0:17:40.905,0:17:46.175 If I picture curiosity tonight and you want to think more about this problem, 0:17:46.175,0:17:48.470 I have a book coming out with my colleagues later 0:17:48.470,0:17:51.165 in the floor called The Question of Competence. 0:17:51.165,0:17:54.900 For tonight, let me summarize my argument this way. 0:17:54.900,0:17:59.895 Medical education is driven by the goal of individual competence. 0:17:59.895,0:18:05.930 Consequently, healthcare is full of highly competent individuals. 0:18:05.930,0:18:08.570 This is a very good thing. 0:18:08.570,0:18:12.425 Individual competence is absolutely necessary but it's 0:18:12.425,0:18:16.730 insufficient to meet the needs of the current healthcare environment. 0:18:16.730,0:18:21.825 Collective competence is an urgently needed adaptation. 0:18:21.825,0:18:27.260 It will require healthcare professionals to think and act differently, 0:18:27.260,0:18:31.315 and it will require patients to think and act differently too. 0:18:31.315,0:18:33.565 When we achieve it, 0:18:33.565,0:18:35.180 I believe it will look something 0:18:35.180,0:18:36.750 like this. 0:19:25.420,0:19:27.990 Thank you.