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Ships without captains

The idea of equality in teams is ludicrous.

Great teams are powerful, when they work together under a shared leadership. Or they are dysfunctional, chaotic and wasteful. This is true for soccer teams, medical teams and governments alike.

As we move from ideas of Stalin, Hitler and dictatorship to ideas of Mandela, Franklin and democracy, we also are moving from ideas of male rule and paternalism to ideas of equality and fraternity. These all seem like good things, good ideas.

In health, we are being moved from ideas of the all-knowing priestesses and priests of medicine; the consultants and the GPs, to ideas of teamwork and collaboration.

In general practice, the political names for this shift are the words ‘primary care teams’ and ‘multidisciplinary teams’. The nurse is an expert and the patient is an expert too. We must all be equal in the team. This is a very seductive idea.

And yet, a family cannot be completely run by the kids, even if collaboration is desirable. Bus routes cannot be completely decided by drivers or passengers, even if the customer is always right.

Patients cannot completely decide on the best treatment options and tell the consultant his/her job.

Especially while the defence ‘the patient told me to do this operation and they signed for this operation, my lord’, is not acceptable in cases of abortion or gross negligence. The ‘team’ may be the patient and their doctor, but the 50:50 vote by the coalition of doctor and patient, and the ‘team’ that has no clinical leadership, will not hold sway in court.

Whether we GPs can do this ‘team’ thing in a 10-minute GP consultation, that is being put under ever more pressure, seems unlikely

It is becoming my experience that ‘the team’ is being used more often than in the past and the idea that you may not be a ‘team player’ is used as if you were a communist in the eyes of McCarthyism in the old US.

Obviously, being a team player is a ‘good’ thing and obviously not being seen as a team player is a ‘bad’ thing in this new, complex, multidisciplinary world.

Speaking of teamwork, the Nazis were very successful teams, as was the Allied team response from Britain, USA, Australia and New Zealand in World War II. Stalin even killed 158,000 of his own people in the name of teamwork. They were called ‘deserters’.

So teamwork can be hammered together by force, as in conscription and threat, by idealism, as in the Irish who went to World War I and the Spanish War, by guile and pressure, as in the song Arthur McBride and some of the romantic advertisements for joining various national armies.

Do we want leaderless teams — collaborative teams without leaders? In health, some of us will be more comfortable with clinician-led teams rather than multidisciplinary teams that lack direction or cohesion. We often note that committees can lead to paralysis, indecision and stagnation. If there are not clear leader roles in these new multidisciplinary teams, we will have the same continuing chaos that one gets with an army that has no generals and a health service where no-one makes pragmatic decisions and takes the responsibility that goes with it.

We, I suspect, are about to see the results of the multidisciplinary team in the next Irish government. It is unusual for a void not to be filled. If there is talk of leaderless teams and governments without leaders, then soon self-made leaders will always assert themselves. Sometimes they assert their power by alleging that no one person should have power.

‘Teamwork’, they shout in accusation, while they assert their own power and values, using the rhetoric of ‘morality’, ‘the people’ and ‘what I saw elsewhere’. They use the words ‘the team thinks’, when they mean ‘I think’. They want to make the decisions without the responsibility.

The bottom line for doctors is that the system is set up so that when something goes wrong, there are many forces that will seek out a clinician to hang. They won’t much care about the ‘team’ or the nurse or the bureaucrat or the things decided at these multidisciplinary team meetings. What one person is to take full responsibility for the perceived failings of the whole system?

There have been and there will always be times when the nurse actually knows more than the doctor and times when the patient actually knows more than the nurse. So we must continue to find ways to honour each person’s knowledge and expertise, at all levels of our complex multidisciplinary teams, while not throwing the baby out with the bathwater and ending up with the chaos and waste of too many generals or leadership by the least experienced. 

Whether we GPs can do this ‘team’ thing in a 10-minute GP consultation, that is being put under ever more pressure, seems unlikely. It is difficult to check with the public health nurse, the pharmacist, the practice nurse, the hospital doctor and the physiotherapist before making a decision.

The new Irish government will grow in democracy and stagnation in order to please the many and be led by none. Coalition, minority government, national government — whatever you want yourself. If we can say: ‘No doctor, no village’, then we might say: ‘No leader, no country’. Someone has to make the final decision, even though they will often be wrong.

They say that good businesses only get decisions right about six times out of 10. But at least they had good ‘teamwork’.

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