Bunches, groups and teams working together.

Last week I needed to see a doctor. As is often the case he was running behind, and as I sat waiting on the exam table I had a chance to reflect on the medical care I had received as a child from my family physician, Dr. Nathan.

I remember Nathan as a very kind man who was a solo practitioner working out of an office in his home. Interestingly, I rarely saw him there, since most of the time he came to my home. He would come alone, whenever we called, no matter what the hour.

Even when I did go to his office, it was just a waiting room with a few patients--no colleagues, no nurse, no medical assistant, It must have been a very isolating professional life.

Even though we still see patients privately, when we close the exam room door behind us we leave the autonomy of solo practice to re-enter the world of medical assistants, pharmacy techs, nurses, billing experts and clinic managers. The practice of medicine in the 21st century is a compulsory team sport. Or is it?

Teams are very special collections of people who behave in a particular manner, and not every aggregation of people constitutes a team. Let's define "bunches" as collections of people who work in the same place but in an uncoordinated manner without common purpose.

Bunches can turn into "groups" when they begin the process of understanding their common purpose and are mindful of each other's parallel efforts. Groups can transform into "teams" when their work toward a common purpose is coordinated, system-focused and committed to continuous process improvement.

A bunch of people can put on basketball uniforms but have no idea how to play the game, a group can practice driving to the basket and honing individual skills, but only a team can play competitively. Successful teams rack up points by passing, not by individuals driving to the basket.

Medical teams?

Many people would opine that medicine is not yet really a team sport. Although very few of us practice autonomously anymore, as Nathan once did, we do a lot of work in bunches and groups.

If we define team properly, very few of our collective interactions as physicians achieve this level of coordinated interaction implied by the concept of team. A team is not just a better group; teams evolve and eventually the whole is greater than the sum of its parts.

So, what is that magic ingredient, and how might one cultivate it to foster better team development?

Teams need coaches to be successful. There are too many interactions, too many details to track, too many individual skill sets to coordinate when true teamwork is required--someone needs to see the big picture.

If we are going to be successful as physician leaders we're going to end up needing to figure out how to coach teams. But how do you acquire this skill? Surprisingly, it's something you already know something about.

It's likely that you have had several coaches since you first started on that youth soccer team or took music or ballet lessons. If you've had children, it's even likely that you've served as a coach on one of their teams.

Because we've been coached and have coached others is likely that we already have an idea about what coaching is. Nevertheless, medical leadership coaching is more complex than it first appears, largely due to the number of hats we must wear in our roles.

In a past issue of PEJ (The Physician Executive, 35(3), May/June 2009) is a wonderful piece by Hicks and McCracken entitled The Coaching Mindset. It gives a great introduction to the concept of coaching in leadership settings, giving examples of the Socratic approach of the coach in assisting an individual to solve his or her problem simply by asking the right reflective questions.

They advocate for a model of asking open-ended questions, affirmation, reflective listening and summarization that is the heart of all effective coaching interventions. This is the core skill set of the effective coach, and it's identical to what you've already learned as part of good patient interviewing during your first year of medical school.

This is the type of coaching to which I aspired as a chief medical officer, but I often found that the product I delivered was necessarily different from what I intended, contaminated by many of the other hats I wore in my leadership role.

One could, of course, argue that those who lead should not also coach. After all, the baseball coach doesn't decide to take a turn at bat. But I think this is an unrealistic approach given the organizational complexity of modern health care.

Coaching is part of leadership, and the successful physician executive learns how to become an effective coach using the core strengths of this model. Coaches frequently have the luxury of coming from outside the organization in a role that lacks conflict of interest, is client-centered and relatively unencumbered by other influences.

Many hats

Physician executives, on the other hand, frequently live at the intersection of several competing forces including regulatory requirements, complex ever-changing alliances between medical staff and executive teams, and a prior history within the organization that differs from the current leadership role.

Yes, we coach, but we also occasionally referee, keep score, take a turn at bat and even run the concession stand. It is just part of the job.

There is also the problem of diminished effectiveness due to familiarity. One of the magical attributes of an external coach is his or her reputation, unaffected by the realities of day-to-day leadership and management.

Prophets are not recognized in their own countries, and physician executives who coach may not have their skill sets appreciated as much as they deserve. No matter how much leadership education you get there will still be a small number of senior physicians who look upon your lack of gray hair as a sign of diminished experience and credibility, and may even remember you as a medical student. You work twice as hard to be perceived as half as good.

[ILLUSTRATION OMITTED]

Finally there is our dual agency role as the bridge between the medical and administrative communities within the hospital. We know that the sweet spot is usually in between, and most of our leadership lives are spent pleasing neither party completely but coming to wise compromises and collaborations that balance quality and efficiency.

So those we mentor and coach in both sectors sometimes harbor a thin thread of skepticism about our motivation. Does this mean that we should not coach as physician executives and turn the leadership development process over to external experts? I don't think so.

There will always be a role for external coaches, but I think it is also possible to hone our coaching skills while taking care to avoid the potential interferences between the many roles we must play.

Mindfulness and self-awareness are the keys to this balance, and you'll need someone to help you keep your perspective. In the real world of physician leadership we rarely have the luxury of the pure Socratic, detached style that is the hallmark of effective coaching. Nevertheless, we need to aspire to that ideal. We can always ask better questions, listen more reflectively, and be better at affirming and summarizing what we hear.

Teams need all these leadership roles to be successful. Over time, a coaching approach can gently transform the hierarchical, autonomous culture of medicine into one of reflective, distributive leadership where asking the right questions is more important than knowing the right answers.

Be patient as you take this journey. You will grow in expertise as a coach while your groups mature into teams.

Edward Walker, MD, MHA

Professor of psychiatry and health services as well as the director of the Healthcare Leadership Development Alliance at the University of Washington, specializing in physician leadership development.

[ILLUSTRATION OMITTED]