Groupthink: What’S So Great About Teamwork?

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 solutions 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 specific 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 Groupthink1,3,9,10 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. Keep moving toward your goals with HUB.

When you partner with us, you’re at the center of a vast network of healthcare industry experts who help practices like yours prepare for the unexpected with:

ý Medical liability and business insurance to protect your practice, your reputation and your assets

ý Employee benefits that help you navigate change and support your people

ý Personal insurance and wealth management to help you protect your home and family

For more information about our tailored solutions, visit, hubinternational.com/rimed

Put our global resources and local expertise to work for you. Daniel Nissi, LIA  800-649-9111  [email protected]

Advocacy | Tailored Insurance Solutions | Peace of Mind COMMENTARY

Physician overextenders

JOSEPH H. FRIEDMAN, MD

11 12 EN

I recently learned from a particular joint problem PA told her that she had degenera- a scheduling secretary or set of joint problems tive joint disease and scoliosis due to that my new patients fre- might explain a peculiar Parkinson’s disease, which is what I quently ask, “Am I going gait. I consider myself a had thought, but I wasn’t sure if this to see Dr. Friedman?” clinical gait specialist. I assessment was correct, which is why I She told me that patients have given medical grand sent to patient to the orthopedist in the often find themselves rounds at other universi- first place, and without an orthopedist’s referred to specialists by ties on assessing gait dis- opinion, still don’t know if it is correct. their primary care phy- orders. I give a talk every I wouldn’t have thought twice about it sician (PCP), only to see year to geriatric internal if I knew this was the spine specialist’s physician extenders and medicine fellows, and opinion. I sent a letter to the spine ortho- not the physician. Many occasional gait lectures pedist to ask if I needed in the future to patients also tell me they’ve never even to other groups. Gait disorders may be specify that he needed to see the patient! seen their (PCP), only the physician complex and I am often stumped, and Not only that, but the same day I asked assistant (PA) or the registered nurse therefore request opinions of others, a patient why he limped after his hip practitioner (RNP). who I believe will have more knowledge replacement. He didn’t know. “Didn’t I am a strong believer in physician or experience in some aspect of the the orthopedist who operated on you say extenders, the cadre of RNPs and PAs problem, since walking problems are something?” “I never saw the orthope- who have been increasing the amount often due to more than one contributing dist.” “Never?” “He came to the emer- and quality of care in the U.S. I have problem, like a brain disease plus bur- gency department before the operation, had the pleasure to work with some on sitis. Most physicians, including neu- but I never saw him again.” In seven a day-to-day basis and can attest to the rologists and orthopedists, are uneasy months! Luckily, this has not been the benefits they provide. However, there assessing gait disorders. So, imagine experience of most of my patients who is a limit to their capabilities and their my surprise to see my referral addressed have had hip or knee replacements, but increasing use as subspecialists without by a PA. I’ve seen patients referred by the fact that this was deemed acceptable oversight has unnerved me. a neurologist to a neurosurgeon, who behavior was a surprise to me. A recent patient, transferring care saw only the neurosurgeon’s PA who I understand the need for physician from another state, thanked me after her then sent the patients to me. The first extenders and have worked with them. examination. “That’s the most complete neurologist would have sent the patient When I worked with RNPs, I used them exam I’ve had since I saw the PA in my to me directly if he wanted my opinion. only to see patients who I had first eval- previous neurologist’s office. The doctor He wanted the neurosurgeon’s, which uated, and I considered relatively stable. never examined me.” What should one he never got. If the patient was found to have not been think of a neurologist who doesn’t exam- I sent a patient to a spine specialist stable, the RNP would get me so that ine a patient? The neurological exam is because I wanted to be sure that her I could review the case, at that time. I the heart of the discipline. scoliosis was due only to Parkinson’s can’t imagine why a fellow physician I have referred patients with gait abnor- disease and not to an intrinsic spine would refer a patient for a non-physician malities to orthopedists to determine if problem. The patient told me that the evaluation. I’ve had patients tell me

RIMJ ARCHIVES | SEPTEMBER ISSUE WEBPAGE | RIMS SEPTEMBER 2019 RHODE ISLAND MEDICAL JOURNAL 11 COMMENTARY

they were referred by a rheumatologist since they lack much experience. Why Author to an orthopedist and saw the health would a PA or an RNP be an appropriate Joseph H. Friedman, MD, is Editor-in-chief “extender.” Imagine, a doctor, possibly a substitute? Emeritus of the Rhode Island Medical Jour- specialist in a related discipline, sends a I now have my patients check to make nal, Professor and the Chief of the Divi- patient to another specialist in a closely sure they will see the doctor, and call sion of Movement Disorders, Department related discipline and sees someone, me for an alternative referral if not. I of Neurology at the Alpert Medical School perhaps a PA with 2 years of training, may lose doctors I’ve dealt with over the of Brown University, chief of Butler Hospi- for an opinion. Aside from betraying a years but why tolerate a drop in quality? tal’s Movement Disorders Program and first profound lack of respect for the referring I am further asking you, the reader, recipient of the Stanley Aronson Chair in physician, it displays one of the many to do the same. Physician extenders Neurodegenerative Disorders. weaknesses in our health care system. have a major role to play in health care. We train too few doctors, burden them They can provide special services, like with time intensive requirements that follow-ups after an operation, learning are not reimbursed and then use less to identify danger signs so that they can well-trained health professionals to help call the doctor on call, to change dress- compensate. This allows more patients ings, reassure the patient and further to be seen in a timely manner, but for supplement the routine care that used consultations, it may actually delay to be provided by registered nurses. They being seen, since the patient may have can likely sew up some lacerations, to wait again, several weeks, or months, apply casts, assist in the interventional to see the doctor. radiology suite, insert canulae and cath- It upsets me to think that my surgical eters, and follow patients in the office colleagues think more of their PAs than who have well-defined problems. If they they do of their medical colleagues or can substitute for the doctor completely, me. I am generally not keen to refer my why not get rid of the doctor and save a patients to newly graduated surgeons, lot of money? v

RIMJ ARCHIVES | SEPTEMBER ISSUE WEBPAGE | RIMS SEPTEMBER 2019 RHODE ISLAND MEDICAL JOURNAL 12 COMMENTARY

Helping Prevent Unintended Teen Pregnancy in Rhode Island Impacts All of Us

DIANA WOHLER, MD; MINOO D’CRUZ, MD; JORDAN WHITE, MD, MPH 13 14 EN

In t he l at e h ou r s o f a b al m y s um m e r However, federal Title X funding is at Providing publicly funded contraception night in Pawtucket, our patient pushed its lowest in nine years.3 Additionally, to one female teenager costs $239 a year; hard, cheeks puffed out and red with new regulations from the U.S. Depart- researchers estimate a savings of approx- effort, beads of sweat at her temples. ment of Health and Human Services imately $6 in medical costs for every $1 Her baby boy was delivered, dried off, (HHS) eliminate the requirement that spent on contraceptive services.11 and wrapped in a blanket before being Title X sites offer a broad range of medi- Title X-funded school-based clinics in handed to her. She held the crying new- cally approved family planning methods RI make a difference in helping prevent born, visibly overcome with exhaustion and nondirective pregnancy options unintended teenage pregnancy. Based and fear. At 16 years old she was sched- counseling including the discussion on our analysis of publicly available uled to start her junior year that fall. of abortion.4 These regulations have data from the Rhode Island Depart- Parenthood was not a part of her imme- been challenged by groups including ment of Health, teen pregnancy and diate plans. Now, as a new mother with the American Medical Association5; birth rates were significantly lower limited support, life would have to wait. however, if these rulings are enforced over time in Woonsocket, where a Title Having easy access to a low-cost clinic by the HHS, this action will restrict X-funded school clinic has existed for with confidential services that addresses teenagers’ access to clinics with com- several years. Central Falls, which has unintended pregnancy and reproductive prehensive contraceptive and family the highest teen pregnancy rate in the health is essential to improving the planning services and would have state, saw an overall decrease in teen health of teenagers in Rhode Island important repercussions on teenage pregnancy rates after the introduction (RI), according to the Rhode Island health in Rhode Island. of Title X-funded programming at the Department of Health (RIDOH), and There is a great public health need for high school’s clinic. helps them meet their educational and these services. About one in four high To address the shortfall in federal economic goals.1 school students in Rhode Island report Title X funding, we urge the Rhode Fortunately, there are three such clin- that they are sexually active.6 Of those Island House of Representatives and ics in the state, housed within public teens who are sexually active in RI, Legislation to appropriate state funding high schools in Woonsocket, Central 88% depended on at least one form of to Title-X funded school-based clinics Falls, and West Warwick. These provide birth control during their last reported to allow them to continue providing a range of low-cost and confidential sexual encounter.7 In RI, there are approx- fundamental reproductive health care, reproductive health services, including imately 20 teen girls out of 1000 every including a full range of contraceptive contraceptive services and supplies, to year who experience an unintended services and supplies. Specifically, we teenagers, thereby reducing barriers to pregnancy.8 urge the House to reconsider H7928, care. These clinics provide these ser- These pregnancies have long-lasting introduced by Representative Kazarian vices under the federal Title X program impact. Unintended teen pregnancy is last January, which would annually that awards nearly 1.2 million dollars to linked to greater risk of future disad- appropriate state funds for contracep- RIDOH, the state’s Title X grantee. The vantages in education, employment, tive services; we also ask that they majority of funds are distributed to eight housing and family structure.9 Only reconsider and include school-based community-based clinics throughout 50 percent of teen mothers have a high clinics in this appropriations bill. This RI.2 Under Title X, teenagers who may school diploma by age 22, versus 90 action will save millions in taxpayer not otherwise seek care due to financial percent of women who do not give birth funds and would contribute to the goal barriers or fear of parental notification as a teen.10 Ensuring that teens have of our state’s teenagers fulfilling their can access affordable, confidential, access to birth control is one of the best potential. v reproductive health services. strategies to boost the graduation rate.

RIMJ ARCHIVES | SEPTEMBER ISSUE WEBPAGE | RIMS SEPTEMBER 2019 RHODE ISLAND MEDICAL JOURNAL 13 COMMENTARY

References 9. Cook S, Cameron S. “Social Issues of Teen Pregnancy.” Obstetrics, 1. Adolescent Sexual Health 2016-2020 RI Profile, Rhode Island Gynecology and Reproductive Medicine. 2017. 27:11, 327-332. Department of Health. 10. Centers for Disease Control and Prevention. Teen Pregnancy in 2. https://www.nationalfamilyplanning.org/file/state-snapshots- the United States. Reproductive Health: Teen Pregnancy [On- 2017/Rhode-Island.pdf line] http://cdc.gov/teenpregnancy/about/index.htm 3. https://www.nationalfamilyplanning.org/title-x_budget-appro- 11. The National Campaign to Prevent Teen and Unplanned Preg- priations nancy. The Public Costs of Teen Childbearing in Rhode Island in 2010 [Online] 2014. http://thenationalcampaign.org/why-it- 4. https://www.kff.org/womens-health-policy/issue-brief/proposed- matters/public-cost changes-to-title-x-implications-for-women-and-family-planning-providers/ 5. https://www.fiercehealthcare.com/practices/groups-file-emer- gency-petitions-to-reinstate-injunction-to-block-title-x-gag-rule Authors 6. Rhode Island Department of Health. Rhode Island Youth Risk Minoo D’Cruz, MD, Brown Family Medicine Residency Program at Behavior Survey. [Online] 2015. http://health.ri.gov/materialby- Kent Hospital. others/yrbs/2015HighSchoolDetailTables.pdf Diana Wohler, MD, Brown Family Medicine Residency Program at 7. http://www.health.ri.gov/flipbook/YRBSResults2017.php#- Kent Hospital. book/11 Jordan White, MD, MPH, Assistant Professor of Family Medicine 8. Maternal and Child Health Database, Rhode Island Department and Medical Science, Assistant Dean for Student Affairs. The of Health. Teen Pregnancy and Birth Rates in Rhode Island. 2014. Alpert Medical School of Brown University.

Aetna is proud to support the members of the Rhode Island Medical Society.

RIMJ ARCHIVES | SEPTEMBER ISSUE WEBPAGE | RIMS SEPTEMBER 2019 RHODE ISLAND MEDICAL JOURNAL 14