A great way to flounder or fail in
system change is to avoid relationship development between team members.
When we examine efforts to integrate collaborative designs,
relationship development is often given short shrift or completely
overlooked. For example, the recently published initial evaluation
results from the medical home National Demonstration Project found team
function suffered (Nutting et al, Ann Fam Med 2009;7:254-260). One way
to build teamwork is to use direct observation of day-to-day
practice. I have been experimenting with this strategy for 15 years
and below I will share some experiences.
Since we began the
mental health internship in collaborative care within our Family
Medicine Residency in 1996, the first month for the new intern is spent
shadowing residents and faculty. Observing helps the intern learn about
the challenges of family practice and it spawns many new relationships.
Our residents and medical students observe one another regularly as
In 1998 I was invited
to spend a year training providers, serving patients and designing a
system of care in an indigent primary care clinic. During the first half
of the year I regularly observed the primary care providers, teaching
them interview and primary care psychotherapy skills and forming
relationships. My behavioral health practice grew rapidly. A few years
before I arrived a local agency had placed a counselor in the clinic.
Six months later the counselor was withdrawn due to lack of referrals
despite being in a clinic where 50% of the patients had one or more
mental disorders. Looking back, it appears that little was done to
create relationships with this new team member.
In my work with
health care organizations to train primary care teams to be more
efficient and effective in communication with patients, a standard
portion of training is peer observation. When the lack of team
coordination between medical assistants and physicians became a common
theme, I began asking physicians how often they had observed their
medical assistants or if medical assistants had observed them. The
answer was almost always the same—team observation had never occurred. I
began having these dyads observe one another and discuss how to
increase the quality and efficiency of patient flow. These primary care
dyads or "teamlets” (see Bodenheimer, Ann Fam Med, 2007, 5:547-461)
immediately began dissecting day-to-day processes to improve systems of
Collaboration is hard
won without adequate relationship development. One way of forming
relationships is to curiously watch each other provide patient care. It
takes time. Trainees need to be sensitive to how feedback is delivered
and remember that watching someone else promotes observation of one’s
Many of you have
other strategies to promote team development or perhaps use similar
approaches. What experiences have you had where team development went
really well or stumbled?