COMMENTARY Groupthink: What’s So Great About Teamwork? KAITLYN MCLEOD, BS, MD’20; EDWARD FELLER, MD, FACP, FACG 8 9 EN Introduction new or lower-status members may “She’s a great team player,” a focus on inclusion, friendship, ac- common accolade, may not al- ceptance and self-esteem conferred ways be a good thing. Working by group affiliation. Thus, non-con- in groups is neither inherently forming individuals may modify good nor successful. When effec- or censor their opinions to avoid tive and efficient, group pro- group rejection, stigma and feelings cesses facilitate problem-solving of inadequacy. In a simple example, and decision-making and are Nobel laureate Daniel Kahneman vital to achieve success.1 Work- reported studies demonstrating that ing alone deprives an individual when a line of individuals incor- of collaboration, input, vali- rectly answers an easy problem, dation, and varied knowledge. such as medical students measuring This commentary explores how interactive, small-group blood pressure, the next student is more likely to mimic processes in Medicine, as in other disciplines, can also their mistake rather than respond correctly, termed a herding have negative effects leading to impaired learning and sub- or bandwagon effect.6 optimal decisions. Applied to educational and clinical set- tings, poor group dynamics can increase medical error and ‘Wisdom of the crowd’ versus individual judgment poor patient outcomes. Our discussion will focus on small In 1906, Francis Galton collected individual responses for teams, work or study groups, committees or panels that a ‘guess the weight of the ox’ competition, an example of approach a specific problem.2 “Wisdom of the Crowd,’’ a belief that the aggregate of solu- tions from a group of individuals is a superior problem-solv- Why can small groups or teams lead to poor decisions? ing strategy than the majority of individual solutions. The Successful groups typically use collaboration, open commu- median guess, 1,207 pounds, was less than 1% off of the nication and shared decision-making; ideally, each member actual weight of 1,198 pounds.7 But, wisdom of the crowd is has a voice. However, group interactions tend to favor clear, most accurate when applied to numerical estimates with a harmonious choices. At times, teamwork may deteriorate correct response such as the number of jelly beans in a jar. into an artificial homogeneity. Groupthink is a group con- The cognitive process in such estimates or specific fact-based formity bias where pressure from oneself, peers, or leaders to questions is not analogous to typical medical decision-mak- produce consensus may limit discussion because potential ing. Aggregate wisdom can be inappropriately applied to dissenters self-censor, change or suppress a contrary opin- complex group decisions which lack a precise answer. We ion or evidence despite actual underlying disagreement.3 must also note that collective wisdom strategies can work. The result can limit group performance by generating fewer For example, in Medicine, selecting the diagnosis of a major- and less creative ideas.4 Perhaps surprisingly, the factors that ity of individual dermatologists or radiologists typically out- affect idea generation, such as trust in teammates, group performs individual diagnoses in mammographic screening stability, cohesion and shared brainstorming can accentuate and skin-cancer detection.8 groupthink.5 Groupthink is often resistant to logical reasoning or spe- cific de-biasing training. These predispositions, which can What aspects of collaboration facilitate groupthink? distort communications, are frequently unconscious and Group membership can be a powerful trigger to go along automatic contributors to sub-optimal judgment.9 (Table 1). with the crowd. Peer pressure to achieve a consensus in Groupthink is not static or immutable. Its expression may homogeneous groups may influence a team member to be magnified by contextual influences during the work day endorse ill-formed opinions of other members. Insecure, which may be ignored, undetected or downplayed (Table 2). RIMJ ARCHIVES | SEPTEMBER ISSUE WEBPAGE | RIMS SEPTEMBER 2019 RHODE ISLAND MEDICAL JOURNAL 8 COMMENTARY Table 1. Cognitive influences facilitating Groupthink 1,3,9,10 Conclusion Cognitive Bias Description Medical education and clinical medicine occur frequently in small groups or teams. Collaborative decision-making Conforming Low status, new or insecure members may stifle bias opinions to avoid stigma, group rejection. most frequently leads to better choices. Familiarity with Herd effect Group behaviors relying too easily on opinions negative consequences of potential group conformity biases of teammates speaking early or assertively. can facilitate better group dynamics and improve group deci- Halo or Uncritical acceptance of opinion of senior sions. We must be wary that groupthink exists. Sometimes, authority bias or experienced member. teamwork can and does fail. Social loafing Less effort if individual accountability is absent or goal viewed as unimportant. References Bystander effect If responsibility is unclear or group too large, individuals decide someone else will act. 1. Kaba A, Wishart I, Fraser K, Coderre S, McLaughlin K. Are we at risk of groupthink in our approach to teamwork interventions in Sunk cost fallacy Unwillingness or inability to modify course when health care? Med Ed. 2016;50:400-408. too much has been invested. 2. Bang D, Frith CD. 2017. Making better decisions in groups. R. Decision inertia Successful groups tend to repeat past decisions. Soc. Open sci. 4:170193. http://dx.doi.org/10.1098/rsos.170193 Motivational Judgment impaired by self-serving individual, 3. Beran TN, Kaba A, Caird J, McLaughlin K. The good and bad blindness group or institutional conflicts. of group conformity: a call for a new programme of research in medical education. Med Ed. 2014;48:851–859. doi: 10.1111/ Longevity bias Homogeneous, long-standing or unchanged teams medu.12510 risk becoming echo chambers of like-minded members. 4. DeChurch LA, Mesmer-Magnus JR. The Cognitive Underpin- nings of Effective Teamwork: A Meta-Analysis. J Appl Psychol. Inbreeding Groups trained at the same institution risk 2010;95:33-55. homogeneity of opinions. 5. Larson JR, Foster-Fishman PG, Keys CB. Discussion of shared and Organizational Potential dissenters self-censor. unshared information in decision-making groups. J. Pers. Soc. silence Silence interpreted as consent. Psychol. 1994;67:446–461. (doi:10.1037/0022-3514.67.3.446) Team-based Emotional contagion. Individual’s burnout 6. Beran TN, McLaughlin K, Al Ansari A, Kassam A. Conformity burnout contaminates other members. of behaviours among medical students: impact on performance of knee arthrocentesis in simulation. Adv Health Sci Educ The- ory Pract. 2012;18(4):589–96. Table 2. Contexts facilitating Groupthink 7. Yi SKM, Steyvers M, Lee MD, Dry MJ. The wisdom of the crowd Fatigue, sleepiness (impairs mood, cognition, performance) in combinatorial problems. Cognitive Science. 2012;36:452–470. 8. Kurvers R, Herzog SM, Hertwig R, Krause J, Carney PA, Bogart Physical and cognitive overload (commitment and focus lag) A, Argenziano G, Zalaudek I, Wolf M. Boosting medical diag- Overlong session, time pressure (interest and attention decrease) nostics by pooling independent judgments. Proc. Natl Acad. Sci. USA. 2016;113:8777–8782. (doi:10.1073/pnas.1601827113) Poor leadership – unskilled, bad agenda-setting, unclear aims, 9. Seshia SS, Makhinson M, Young GB. Cognitive biases plus’: authoritarian covert subverters of healthcare. Evidence Evid Based Med. Decision fatigue (cognitive exhaustion after tough, stressful day) 2016;21:41-45. 10. Aramovich NP. The Effect of Stereotype Threat on Group Ver- Unclear or unshared mental models sus Individual Performance. Small Group Res. 2014;45:176-197. Distractions, interruptions (force attention to shift from discussion) 11. Eichbaum Q. Collaboration and teamwork in the health pro- Burnout – individual or team-based fessions: Rethinking the role of conflict. Acad Med. 2017; 93: 574-580. Sub-optimal meeting space (noisy, wrong size or shape, lack of 12. Eisenhardt KM, Kahwajy JL, Bourgeois LJ 3rd. How manage- inclusive seating) ment teams can have a good fight.Harv Bus Rev. 1997;75:77–85. Inability to embrace creative aspects of uncertainty or conflict Authors Kaitlyn McLeod, BS, MD’20, Warren Alpert Medical School of Embracing dissent in teams Brown University. Group conflict or uncertainty may disrupt, distract or poison Edward Feller, MD, FACP, FACG, Clinical Professor of Medical individual and collective success.11 But, striving for consen- Science at Brown University; Co-Editor-in-Chief of the Rhode sus or unanimity can undermine healthy skepticism by Island Medical Journal. undervaluing the benefits of inter-member disagreement. By Correspondence avoiding conflict, groups may never ask “what are we miss- Edward Feller, MD ing?” Conflict may foster creative ideas by expanding the Box G- M 264, 222 Richmond Street range of options. Comfort expressing non-conforming ideas Brown University, Providence, RI thrives when individuals feel safe despite heated debate. 401-863-6149 Conflict can destroy groups or be a productive, energizing [email protected] source of learning, leading to superior outcomes.12 RIMJ ARCHIVES | SEPTEMBER ISSUE WEBPAGE | RIMS SEPTEMBER 2019 RHODE ISLAND MEDICAL JOURNAL 9 Life is motion. 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