Insights (Essays)

Insights (Essays) January 2014

Do You Work Well With Others? It Depends On Whom You Ask

Adrienne Melck, Trina Montemurro, Marlies van Dijk, Kevin Smith and Hugh MacLeod

Members of the surgery teams at Vancouver’s St. Paul’s Hospital were perplexed. Surgeons, nurses and anesthesiologists had recently completed a teamwork and communication survey, and they were surprised to see how their scores compared. Most striking was how the score that nurses gave their collaboration with surgeons was half of the score that surgeons gave their collaboration with nurses. 

How could the two groups have such different perceptions? Adrienne Melck, a surgeon at St. Paul’s, wants to answer that question and then begin improving teamwork levels in the hospital’s operating rooms immediately. “Teamwork is essential for a patient to be safe during surgery,” she said. “This evidence is getting stronger and stronger.” 

Adrienne’s colleague, anesthesiologist Trina Montemurro, explained it this way: “If I come into the room grumpy and snapping at the nurse, what are the chances she’ll tell me that I forgot to put the pulse oximeter on my patient?” 

Adrienne and Trina aren’t sure why their teams are so dysfunctional. They also aren’t alone: 13 other operating rooms in BC found the same result and the situation exists in the US, according to Marty Makary, a surgeon at The Johns Hopkins Hospital. Makary published his findings in a 2009 study titled, “The Eye of the Beholder,” and elaborated upon them in a best-selling book: Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare.

The Ghost of Healthcare Consciousness appears and says:

“Often you forget the simple … like how your behaviour appears to others, and how poor behaviour gives others permissions to do the same. If your behaviour is dismissive, others’ behaviours will be dismissive. In healthcare you do not make things, you are a touch business. Great care flows from great relationships between care providers, patients and families. I wish you could fully understand, appreciate and accept that culture in a hospital is tribal; it lives and breathes at the ward level. The reality is that there are significant cultural differences between shifts and even team members. Furthermore, a unit’s culture can be influenced – both negatively and positively – by a single individual. Often I hear this: ‘He/she is a great care provider even though he/she has terrible people and bedside skills.’ They in fact intimidate, frighten and stop the quality and patient safety risk conversations.”

The surgeons at St. Paul’s Hospital think that their communication levels might be poor because they were trained to be held solely responsible for a patient’s care and put in a position of ultimate control. “No one taught me leadership skills or how to be a good manager,” Adrienne said. “Just because you are a technically sound surgeon does not mean you are necessarily a good leader.”

But a shift is under way at St. Paul’s Hospital. Performance reviews now include elements of professionalism. Also, new surgeons are being trained in operating rooms that use the Safe Surgery Checklist and save lives because they do so. Trina has noticed a difference in how surgical team members interact with each other: “We were not trained to share our concerns for the patient with our team members in the operating room. It was something we just kept to ourselves.”

And Adrienne said the proof is in the pudding: “Data is building and starting to become robust. Good operating room culture and communication is reducing adverse events.” 

Adrienne is trying to improve communication by encouraging her teams to use agreed-upon phrases or terms in order to signal concern, set the stage for raising questions about what is happening, or indicate intense times where a surgeon needs to devote his or her full attention to the procedure.

“We could say: ‘This is not an ideal time for a question; this is a tricky part of the case.’”

The St. Paul’s Hospital team faced its issues head-on. The surgeons, nurses and anesthesiologists who filled out the survey were asked what was behind their answers. This wasn’t a comfortable process – a colleague from another discipline sat down with each group – but the results were positive, simple and could be implemented right away. Suggestions included discussing details of a case with residents outside of the theatre, avoiding questioning the anesthesia technique in front of the patient, and informing nursing and anesthesia team members well before a surgery of the position that the patient should be in. 

Trina and Adrienne see numerous other opportunities for improvement, many of which involve using the surgical checklist. If team members are having a side conversation during the checklist, it should be acceptable for other team members to ask them to stop. Other ideas include practising responses to intraoperative crises and publicly posting checklist compliance for all of the surgical specialities on the units. “Maybe nurses shouldn’t hand over a single instrument until the entire team does the time out portion of the checklist,” wondered Adrienne. At a minimum, administration and leadership should be modelling these behaviours. 

As we learn more about the importance of effective teamwork and communication in surgery, we can expect to find more perplexing survey results like Trina and Adrienne encountered. It’s our response, and whether or not we ask the often uncomfortable question, “Why?”, that is truly illuminating – and life-saving.

Three recommendations:

  1. Dig deeper! Follow up on surveys and discussions and ask: “Are there ways we can improve? And what can each of us change to foster an environment of strong teamwork and communication?”
  2. Encourage a culture where team members are safe and encouraged to address practices and behaviours that create an unsafe environment for the patients.
  3.  Implementation of teamwork and communication training for surgical teams.

We close with a passage from the essay, “Four Mindset Shifts”:  

“We see a potential paradox emerging. Culture and values are not static, but a commitment to a condition of being. It is all about coherence, the internal order or harmony among the relationship patterns. When the healthcare organization or system is coherent virtually no energy is wasted because of the internal synchronization among the parts. Increased coherence enables the emergence of new levels of creativity, innovation, cooperation, productivity and quality on all levels. We must begin to bring more heart to what we do and to make it safe for people to bring their own hearts into the workplace. This is a time when the health system needs all the energy and passion they can get to transform our systems and people into new ways of working together and that passion will not be available without engaging the heart. Engaging the heart means incorporating respect for the individual. 

“The nature and role of information has to change from being restricted and used for power to being openly shared, to be available to everyone like the air that we breathe. Relationships will flourish when barriers between and among organizational spaces are removed. People will be able to – even compelled – to bump into each other and literally create and circulate new information. As new patterns of interdependence grow, trust will begin to increase due to the recognition that listening skills with a willingness to be influenced become critical. With this, a deep appreciation for the fullness of the healthcare system’s diversity begins to grow.”

Join the next week's conversation titled: Resiliency – Time for a Conversation

About the Author(s)

Adrienne Melck, General Surgeon, St. Paul’s Hospital
Trina Montemurro, Anesthesiologist, St. Paul’s Hospital
Marlies van Dijk, Director of Clinical Improvement, BC Patient Safety & Quality Council
Kevin Smith, Digital Media & Communications Specialist, BC Patient Safety & Quality Council
Hugh MacLeod … Patient, Father, Husband, Brother, Grandfather … Concerned Citizen


Makary, M. 2012. Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare. Bloomsbury Press.

MacLeod, H. and R. Alvarez. 2013. “Four Mindset Shifts.” Longwoods Ghost Busting Essays. 


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