David J. Schleich, PhD
Education
Like all professional education preparatory programs, medical education has 3 tiers, elucidated well by Donald Schon in his seminal 1986 book, Educating the Reflective Practitioner. The tiers include the basic sciences, applied sciences, and a practicum of some sort. In our field, this translates into discipline-specific classes in tier 1, such as anatomy, physiology, histology, pharmacology, and so on; and applied sciences in tier 2, like botanical medicine, homeopathy as a medical system, physical medicine, etc. In the final tier or stage of medical education, we conjugate our senior interns through a challenging clinical regimen. The least common denominator throughout this process, though, was a framework designed for individual learners. Translation: “sage on the stage” teaching, passive individualized delivery and receipt of information and content, and clinical training choreographed by autonomous supervising physicians. Clinic competencies were tested individual by individual. We have, though, learned much in the ensuing years about team learning, teaming up teachers, and teaming up program design and delivery. A half-century back, my Grade 6 teacher, Mary Goggin, knew that.
Miss Goggin was a Commonwealth Exchange Teacher from Ireland. She had many tales and related counsel gleaned from characters who worked the farms and little shops in and around Cahera, Drimoleague and Meenies, tiny villages back then in County Cork, where she was from. Our teacher would always draw on such wisdom from those whom she called “my life team,” and she wanted us to get in the “team habit” as soon as we could. Smack dab in the first week of that school year, in fact, she was introducing us to the importance of collaborating with each other. As part of her pitch, she referenced Mr Teagan O’Neill from her own personal “life team.” We knew that he and his wife Nola were real because their picture was on our class bulletin board. They were local farmers from Cahera who had unerring advice on most matters. In this instance the O’Neills’ particular wisdom was related to Miss Goggin’s comments about how we would be working in teams all year. She further explained that that specific advice about teams, when she first heard it back in Ireland, had been directed by “mother and father O’Neill” toward their son, Quinn. Quinn listened and learned because his parents were very much part of his own “life team.”
Apparently, Quinn did not want to farm like his parents and his grandparents before them. Rather, he and his new bride, Kate, wanted to open a pub to make their living. Miss Goggin reported that Mr and Mrs O’Neill were disappointed. Even so, they proffered counsel, as any good team member might. Teagen is reported to have said, “Shearin’ fleece, servin’ beer; s’all the same, lad. Don’t matter which, ‘cause you and Kate’ll be needing a new team who know what you’re about. They will shorten the road.” Miss Goggin said that Nola O’Neill weighed in at that same family meeting too. She added, “May the roof above you never fall in, and may your team never fall out.” Miss Goggin was teaching us that day those around us make the best – and sometimes only – teams we have.
The Team Habit
It went like that all year long. Mary Goggin frequently called on the legendary wisdom of the O’Neills and others who seemed to have wisdom available to apply to any problem. She admired them so much that she had affixed a picture of a group from Ireland to the class bulletin board. There were 7 in that group, including the O’Neills and stolid, unsmiling County Cork farming people standing in front of a mossy rock fence. In the center, surrounded by her “life team,” was Mary Goggin holding her newly minted teaching diploma, all smiles and light. We didn’t understand the words on the diploma she was proudly holding, but we knew it was official and that the entire group was celebrating: Bilingual Certificate, National Schools, AN ROINN OIDEACHAIS 1954. She gave us a copy of that picture at the end of the year. What is useful to note is that Miss Goggin came out of a very repressive and controlling educational system at the time. She became a certified teacher, but found her voice and her style as a teacher with the help of many mentors. She had written “Life Team” above that picture. She also had affixed a map of County Cork to our class bulletin board, above which map were the words, “The Centre of The Known Universe.” What?
From the get-go, Miss Goggin organized our class of 35 into 7 rotating “teams for life,” as she called them. She routinely assigned tasks of all kinds to those constantly shifting teams. Of course, we snubbed the Grade 5s and the Grade 7s and 8s who weren’t doing teams. Because our teacher was very cool, we also wondered how long she might last, given the ultra-conservative place our school was. We recognized that we were lucky to have such a different teacher, lucky to be doing things differently than others in the same school. And, as we began that year of teams and groups, at first we squabbled about which team was on top, which team was on bottom, and who got whom for the team of the day. Gary Enright could do fractions and decimals like nobody’s business. Wilfred O’Donnell knew history like crazy. Eileen Demarco could spell big-time. Philip Bonicci could sing “Dark Moon” like Pat Boone. Diane Belaysis liked boys with brains, but the only boy in the class as tall as she was, was Philip. My point here: after all these years I remember my Grade 6 classmates vividly and we changed, the whole lot of us. I attribute it to those hard-working teams. We were challenged for 40+ weeks and the bonds were strong. Early rivalries shifted into very enduring friendships. Mary Goggin went back to Ireland at the end of that school year and was a pen-pal with many of us for years and years. I even went to visit her as a young man with long hair on a long trek through Europe.
I remember the very first team task. We were all poised, thinking we were going to be competing with the other teams on some task or challenge. Not! Miss Goggin announced, on that first memorable day when the “team talent” got launched, “the best way to learn is to teach.” She explained that if there was something one person didn’t get on any particular day, then every team leader had to “teach” it back to his or her team the day after she taught it. Duh? She polished the assignment with, “Mr. O’Neill says that Quinn had to teach him the next day what he didn’t know how to do the day before.” Duh again. “Like what?” Philip Bonicci wanted to know. But what if he couldn’t ever get it, we complained? “There’s always the next day for teaching it back, until you do get it,” Miss Goggin assured us. Teaching it back?
Another of her magic tricks was to have 2 teams debate an issue, 5 people doing the research, and 2 people doing the debating from each respective team. We had Friday round-robin debates on all kinds of questions. The winning team, though, didn’t get a trophy or something. The winning team got more work. They had to “coach” the losing teams in how they won.
At the time we didn’t know that what we were doing was learning how to value the concept that collaborating with others was a lifetime skill. We did not know how special it was, but we did know that it was fun. One day, somewhere along this happy continuum, though, I must have exhibited a particularly corrugated brow during one of Miss Goggin’s science lesson on “states of matter.” She busted me (and others who, though more skilled at not giving away their terror at being found out to be not getting it, sighed relief) as I struggled with trying to understand “kinetic energy” and “latent heat.” I could not get the concepts, for some reason, and was horrified when she told me to teach “latent heat” back to my own team group the very next day. Good grief.
Let me tell you, though, that in doing what she advised, I got it. Because I had to get ready for the questions and quizzical looks of team classmates, I drilled down into the topic and was as prepared as I could be for explaining the notion of how melting (or freezing, if one thought about it backwards) worked. Miss Goggin had told us that it was possible to have water in solid state, and water in liquid state, at exactly the same temperature. That it took extra energy to convert water as a solid into water as a liquid, but that same energy did not necessarily increase the temperature of the resulting water, baffled me and, as it turned out, baffled most everybody else in the class too, except Wilfred O’Donnell, the resident brainiac who invariably tormented me with questions. By the time I had “taught” this to my team, I had experienced an epiphany. The epiphany was in getting it that the heat which broke the force of attraction between particles was not siphoned off to increase the kinetic energy of the particles themselves, thus no rise in temperature in the melted water. Easy. I recall this phenomenon to this very day.
It went like that all year. One time we were debating the notion of “might is right” in the history of nations. Different teams had different approaches to the affirmative and negative of that particular conundrum. Miss Goggin often asked one of us to “teach back” to our team that week confounding topics like that. Clever pedagogy. We all got used to responding to our classmates’ questions and gradually kinder teasing. We got so used to not learning alone that year, that when Grade 7 rolled around and Mr Whitney Humphrey sidled into his “sage on the stage” routine, we responded by creating learning teams of our own. He didn’t like it too much.
What that Grade 6 cohort internalized was that we were best together, helping each other. We had to get good at figuring out our differences, navigating conflicts, talking clearly, avoiding any kind of bullying. We got pretty flexible, and definitely got good at shifting gears. We did have our wobbles, but because we rotated through many team configurations that school year, we came out the other side as confident individuals who knew how to get together on a task. This attitude and those skills stayed with me. For example, the very next year I made the high school basketball team, even though I was short and couldn’t dribble a ball up or down the court very well; what I had was great accuracy in sinking the ball from almost anywhere. I convinced the coach that the team could count on me to deliver hoops from anywhere. I asked him, though, if I could count on them to dribble the ball and fake out the other team. The tutelage of that 5-foot Irish woman from Cork and all those “sticking together to get the work done” stories from farmer O’Neill are with me yet.
Team-Based Education
At university I chose a business degree program and brought Mary Goggin’s magic with me. I soon discovered that team training and team work were hallmarks of curriculum delivery in that business school. Over the years I became aware of manifestations of team-based education and training in all kinds of corners of society, such as the military, emergency responders, community policing teams, fire and rescue squads, event coordinators, sales teams, and even political parties. It was, though, when I found my way into the medical-education field a quarter-century back, that I realized there might be some catching up to do.
Tuckman’s (1965) early work about how teams take shape is as valuable now as it was over a half-century ago as a guide to how to incorporate Goggin Magic into medical education, in the sense of encouraging such team design, delivery, and continuous improvement. Whether our intention is to move toward the notion of “patient-centeredness” as the norm by eschewing individual clinicians motivated by individual achievement, or whether we need principal investigators to collaborate with others to get research questions answered, team skills can help. What lies before us, notwithstanding the bruising being applied to the Affordable Care Act’s notions of coordinated care and medical homes, is a brave new world of medical education (and research) where common commitment coupled with shared skills, shared information, and shared goals can be hugely effective. As Baker et al (2005) put it, there is a place for collective performance where mutual, rather than individual, accountability in the landscape of medical education obtains. I wondered more than once about how to take the best of Mary Goggin’s ideas, learned from Teagan and Nola O’Neill and the other farmers near Drimoleague, and apply them to what we do in colleges and universities with teams of academic choir soloists all over America?
Four Stages in Team Development
Tuckman taught us that the 4 stages in the development of a team (forming, storming, norming, and performing) apply as much to students as to their teachers. Students in their study groups can assimilate all that information in digestible chunks more handily, and into the bargain, retain more of it. Furthermore, if we build into the process of our delivery opportunities for our learners to reconcile in their own heads what they weren’t sure about, we’d be optimizing learning. The teacher becomes the student and the student becomes the teacher, as Miss Goggin used to put it. Gagne (1970) and Weber and Karman (2005) confirm with their research that such collaborative learning stimulates more active engagement and better retention than passive learning anytime. What Teagan O’Neill would say, as reported by Miss Goggin, “If you’ll be wanting to get more wool from that sheep, ask around and go deep; there’s farmers here what know and will be showing you if you ask.” In-depth learning, in other words, can be beautifully reinforced by teamwork, collaborative knowledge-sharing, and reinforcing of what is learned.
The lessons in our health system’s delivery habits are very tough to grapple with. Solutions include team-training, of both teachers and students, all along the path of their learning and credentialing. For example, multidisciplinary and team-based groups need to be encouraged more broadly. A splendid example of this is reported by Morrison et al (2010) who remind us about such a process from the aviation industry, called “crew resource management” (CRM). CRM has been very successful in reducing severe aviation errors and enhancing industry safety – great goals for medicine too. Clancy and Tomberg (2007) remind us that this kind of approach is very present in American health systems in something called the “TeamSTEPPS™” program (Team Strategies and Tools to Enhance Performance and Patient Safety). Morrison et al, though, point out that because students in medical schools are not officially on hospital teams, they don’t benefit from early team-training and can’t contribute easily to the units and departments (such as ORs, labor and delivery, ICUs, medical center clinics). Duh.
What are those team skills, again, that are so important to coordinated care? Dunnington and Williams (2003) summarize them beautifully: “effective communication with patients and families, patient counseling and education, cooperative work-sharing with health care professionals, and the ability to instruct students and other health care professionals” (p.257). The ACA contemplates doctors (allopathic and naturopathic), pharmacists, nurses, social workers, and others sharing responsibility for patient care. Team approaches are more valuable than ever.
You’d swear that some of those who have been thinking and writing about the power of teamwork in medical education, in fact in education generally, had been in Mary Goggin’s Grade 6 classroom in southwestern Ontario back in 1957.
References:
Baker, D. P., Gustafson, S., Beaubien, J., et al. (2005). Medical Teamwork and Patient Safety: The Evidence-Based Relation.Agency for Healthcare Research and Quality, Rockville, MD. Available at: https://archive.ahrq.gov/research/findings/final-reports/medteam/. Accessed January 16, 2018.
Clancy, C. M., Tornberg, D. N. (2007.) TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual, 22(3), 214-217.
Dunnington, G. L., Williams, R. G. (2003). Addressing the new competencies for residents’ surgical training. Acad Med, 78(1), 14-21.
Gagne, R. M. (1970). The Conditions for Learning. 2nd Ed. New York, NY: Hold, Rinehart and Winston.
Schon, D. A. (1987). Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. San Francisco, CA: Jossey-Bass, Inc.
Tuckman, B. (1965). Developmental sequences in small groups. Psychol Bull, 63, 384-399.
Weber, M. D., Karman, T. K. (1991). Student group approach to teaching using Tuckman model of group development. Adv Physiol Educ, 261(6 Pt 3), S12-S16.
Image Copyright: <a href=’https://www.123rf.com/profile_cienpies’>cienpies / 123RF Stock Photo</a>
David J. Schleich, PhD, is president and CEO of the National University of Natural Medicine (NUNM), former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as vice president academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto (PhD).
