April 2009

Jared N. Schwartz, MD, PhD

Taking ownership of team leadership

They had to appreciate the idea that the values of the world we inhabit and the people we surround ourselves with have a profound effect on who we are.
—Malcolm Gladwell, Outliers: The Story of Success

My daughters live in New York City; LaGuardia-to-home is a familiar commute. So we were drawn to the January news accounts of an Airbus 320 bound for Charlotte that was forced to land in the Hudson River. Media coverage focused almost exclusively on the pilot, Chesley (Sully) Sullenberger III, whose patience with repeated questions about the “miraculous” marine landing began to wear thin over the next few days. This has been too much about Sully and not enough about the team, he finally said. Pilots and crew practice for emergencies. We did what we are trained to do.

In a later interview, Sullenberger said he didn’t have to think in the minutes available to act; experience and long-practiced protocols had enabled a near-autonomic response. His team, too, knew the drill. Together, they averted disaster.

Although our work is less dramatic, standard terminology and procedure protect our patients in the same way they protected those passengers. Within the College, best practices are the foundation for laboratory accreditation and the focus of much of our work. Last fall we kicked it up a notch with the introduction of the CAP Pathology and Laboratory Quality Center. The Center will foster partnerships with other stakeholders in development of best practices and clear standards for the use of new and existing technologies across the system of care. M. Elizabeth Hammond, MD, a pathologist at Intermountain Health Care and LDS Hospital who helped to launch the successful CAP/American Society of Clinical Oncology collaboration to develop guidelines for HER2 testing, is at the helm.

Within the hospital, laboratory interface is organic; we affect every patient’s well-being in one way or another. The pathologist’s responsibility to the patient originates the moment tissue is excised or blood is drawn, and it continues through testing and documentation. Afterward, we stay involved, consulting on treatment options and monitoring patient progress.

Treating physicians, surgeons, phlebotomists, nurses, messengers, and processors are members of the preanalytic team; after testing, transcriptionists, information services professionals, and biospecimen resource managers come off the bench. How do we keep everyone on the same page? We do what comes naturally to the pathologist. We mentor, we teach, and if we’re smart, we brainstorm about it.

The quote at the top of this page is taken from Gladwell’s most recent (and excellent) book, which examines the idea that culture (and happenstance) can foster qualities that translate to extraordinary success. The contexts within which we live, learn, and work shape perspectives and behaviors in sometimes critical ways.

Smart leaders understand this; in the hospital, they find ways to enable team members to see how they contribute to the system of care. For example, Dr. Hammond and her pathology technologists have talked about why it is important to record the exact time a specimen is removed from a patient. She’s also talked with the operating room staff about it, and a breast cancer surgeon has reinforced the message. It is rare, now, for a specimen to come in without that information. Dr. Hammond also checks to see that time of fixation is properly recorded; if it’s not, she requests it and makes sure everyone understands why. Liz routinely sits down with her information services staff to explain why she is asking them to query the database and what she hopes to learn from it; the analysis commentary is richer as a result. When people innovate, improve, or meet a goal, Dr. Hammond says, we need to let them know we’ve noticed. It’s all about communicating in context. Taking the time to help the members of your team understand exactly how their work affects patient outcome motivates like nothing else.

Cathy A. Petti, MD, an infectious disease physician with board certification in pathology and medical microbiology, is another example. Dr. Petti divides her time at the Palo Alto Medical Foundation between direct patient care, directing a laboratory, and research to improve the use of laboratory informatics in clinical decisionmaking. She conducts daily rounds with residents, treating physicians, and the laboratory staff. Not long ago, a medical technologist mentioned on rounds that an extremely rare Pseudomonas had just been identified via gene sequencing for the second time in as many weeks. Because communication channels were already in place, they quickly determined that both samples had come from patients at a local children’s hospital, and that both had undergone bronchoscopy. The children’s hospital was able to correct the problem before the infection spread further. One astute technologist prevented a serious outbreak because the system of care recognized her expertise and encouraged her to speak up.

“Team building” of the kind just described strengthens ties within a group. We need to pursue another form of team building as well: strengthening ties traditionally thought to be external.

Scott W. Binder, MD, senior vice chair and director of pathology clinical services at the Geffen-UCLA School of Medicine, makes a practice of reaching out to other specialists who are outsourcing high-volume tests. Dr. Binder picks up the phone and suggests they sit down to talk about collaborating on an initiative to bring those tests inside. Telepathy doesn’t work in medicine, Dr. Binder says; you need to talk with your colleagues, learn what they are looking for, and help them find it. We’re all under the same pressures, he points out, but other specialists will be far less likely to see themselves in competition with the laboratory for scarce revenues if they are already collaborating with you to advocate for interdisciplinary solutions.

Pathologists have a lot in common with that airplane pilot. Like him, we know that professionalism across the team is what brings our patients safely home. When we take ownership of team leadership, we are just doing what we are trained to do.