Walking the Plank: New Team-Based Leadership Models in Medicine Supplant ‘Captain of the Ship’ Mentality

Over the past year, the cardiac ICU team at Cedars-Sinai Medical Center has learned firsthand the challenges that come with breaking down power dynamics as part of a system-wide overhaul of the multidisciplinary teamwork needed in patient care.

“We are not advocating for an abdication of personal responsibility,” they write, but say that too much focus on who is in charge distracts clinicians from “more important actions.”

In a viewpoint published online this week in JAMA Surgery, Michael Nurok, MBChB, PhD, of Cedars-Sinai Heart Institute (Los Angeles, CA), and colleagues describe the structural and economic rationales underpinning the need for change. As contemporary healthcare systems have become more complex, they write, caregivers from all specialties have found themselves involved in a “complicated dance of overlapping team-based care activities” that negate the “captain of the ship” philosophy from a bygone era.

“When things go well, no one is really focused on who’s in charge because it’s seamless,” Nurok told TCTMD. “When there are breakdowns in communication, there’s frustration around people being informed and it’s really, at that point, a question of who is in charge.”

To better avoid those scenarios, Nurok approached his institution about a year ago to investigate the processes and procedures considered standard in his ICU. The project was originally focused on cost, said Joseph Castongia, MHA, who manages care innovation and design at Cedars-Sinai and has been leading the project from an administrative standpoint. “Ironically enough, we ended up uncovering some very deep-seeded human elements to what actually drives the amount of care patients receive or don’t receive,” he told TCTMD in an interview.

Castongia spent months shadowing the care teams and interviewing everyone including cardiac surgeons, intensivists, the mechanical circulatory support team, the transplant team, nurses, and pharmacists, and found that care was being distributed in a “really fragmented and siloed manner.”

Observations detailed by the authors included:

• Procedures and patients have become more complex
• Risk of physician burnout needs to be factored into the equation
• The question of who is captaining the ship can detract from good patient management and typically comes to a head only when something goes wrongGood teamwork and communication are skills every bit as important as procedural skills; both require training and oversight

‘One Person Can’t Do It All’

Leadership styles are formed as far back as medical school and residency, Castongia observed. Surgeons are taught to “make quick and effective decisions and be confident about those decisions and have control over the situation whereas maybe those more on the medicine side have more of a ‘let’s try this and see if it works’ type of mentality.” As one could imagine, these thought processes often clash, he said.

Moreover, hospital leadership models stem from the former era of medicine, argued Nurok. “Historically, when medicine was less complex, you had the concept of one doctor who could really take care of everything. But the reality is that it’s not just one person who’s looking after the patient,” he said. “One person just can’t do it all.”

That is something patients also need to be made aware of, the authors argue. Part of the notion of a ship’s captain directing care comes from the informed consent process, which can give patients the erroneous impression that a single physician will be doing the bulk of their procedure. Instead, the patient needs to be informed—and consent to—a “matrix environment” of multidisciplinary care. 

To address this outdated leadership model, Nurok’s team has focused on the flow of care and creating a system that “really supports and incentivizes physicians to work together.” Among their recommendations: reward teamwork and communication; provide training and mentorship for collegial, communicate in nonhierarchical manner; and address physical and administrative barriers that “silo” different departments. At Cedars-Sinai, all ICU patients are now treated in a single tower and the team has instituted regular in-person meetings and financial incentives for caregivers to participate.

Parallels to the Heart Team Concept

Their ideal multidisciplinary approach is “the same” as the heart team concept often used in the interventional cardiology and cardiac surgery communities, Nurok said. “Everyone acknowledges that it’s hard to do, but when it’s done properly, I think that’s when it’s most rewarding for both the patients and for caregivers.”

For a team-based approach to truly work, he said there needs to be strong commitment from leadership, “but there also has to be ground-level support and encouragement for it.”

Castongia’s advises other institutions seeking to implement more multidisciplinary teamwork to understand the individuals within the teams. “It goes into how people value themselves and how people perceive themselves,” he said. “You go into egos. You go into power conflicts. And [if] your goal is to truly institute change within your organization directly, I don’t know that you can do that without first… really [connecting] with the people and [building] the relationships.”

Even though this legwork can sometimes “feel a little bit like trying to herd cats,” Nurok said, the payoff is encouraging. While they do not have any data yet to show whether or not their efforts are resulting in better outcomes or cost-savings, his “gut instinct” is that they will. “Certainly it’s one of those things where everyone can feel like it’s less frustrating to provide care across the board when everyone is communicating more seamlessly,” Nurok commented.