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