Key points

Importance of teamwork in burn care

If you want to go quickly, go alone. If you want to go far, go together.

Burn care arguably represents the perfect confluence of art and science in modern medicine. Advances in burn care, based on clinical empiricism, translational research, and the application of basic science knowledge, have yielded staggering improvements in survival after thermal injury, from the Cocoanut Grove fire in 1942 to the volatile post-9/11 world of the early 21st century. We have reduced mortality, shortened lengths of stay, and decreased complications, through both incremental and disruptive innovations in rescue, resuscitation, and resurfacing.

Perhaps the most important factor contributing to these improved outcomes, however, has been the evolution of team-based care. Although the burn surgeon still remains the leader of these teams, successful treatment depends on the coordinated, collaborative efforts of individuals, such as nurses, anesthesiologists, respiratory therapists, occupational and physical therapists, dieticians and nutritionists, psychosocial experts, chaplains, and even family members. As we move toward quality of life as a primary outcome measure, the need for great teams becomes even more paramount. Success in rehabilitation, reconstruction, and recovery depends on shifting our research focus, as we help burn survivors transition from patient to person, as they return to school, work, and society.

Importance of teamwork in burn care

If you want to go quickly, go alone. If you want to go far, go together.

Burn care arguably represents the perfect confluence of art and science in modern medicine. Advances in burn care, based on clinical empiricism, translational research, and the application of basic science knowledge, have yielded staggering improvements in survival after thermal injury, from the Cocoanut Grove fire in 1942 to the volatile post-9/11 world of the early 21st century. We have reduced mortality, shortened lengths of stay, and decreased complications, through both incremental and disruptive innovations in rescue, resuscitation, and resurfacing.

Perhaps the most important factor contributing to these improved outcomes, however, has been the evolution of team-based care. Although the burn surgeon still remains the leader of these teams, successful treatment depends on the coordinated, collaborative efforts of individuals, such as nurses, anesthesiologists, respiratory therapists, occupational and physical therapists, dieticians and nutritionists, psychosocial experts, chaplains, and even family members. As we move toward quality of life as a primary outcome measure, the need for great teams becomes even more paramount. Success in rehabilitation, reconstruction, and recovery depends on shifting our research focus, as we help burn survivors transition from patient to person, as they return to school, work, and society.

Leading the team from good to great

Teamwork is the ability to work together toward a common vision, the ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.

Great teams almost always come from good teams. Although good teams deliver results and offer value to stakeholders, great teams exceed expectations and create lasting value. Considerable scholarship into the formation, development, and execution of complex, multidisciplinary teams reveals a common thread: great teams require discipline. Deliberate, focused performance and practice is an essential approach that enables a team to go from good to great by encouraging shared leadership roles, individual and mutual accountability, collective purpose, active discussion and problem-solving, measurement of performance, and closure of feedback loops. Good teams cooperate; great teams collaborate.

Jim Collins analyzed 11 publicly traded companies that achieved good-to-great stock market growth and discovered “why some companies make the leap . . . and others don’t.” The 7 characteristics responsible for the transition of these companies into industry stars include:

• 1.

  Humble leaders who are fiercely driven to do what is best for the company

• 2.

  First who, then what: getting the right people on the bus

• 3.

  Confronting the brutal facts, but never losing hope

• 4.

  Aligning what you are passionate about, with doing what you are best at, and what creates value

• 5.

  Establishing and modeling a culture of discipline to make the right, but sometimes difficult, decisions

• 6.

  Implementing technology accelerators, to take advantage of information capital, which is cheap to store but precious in utility

• 7.

  Spinning the flywheel to gain momentum, such that many small initiatives are additive and even synergistic, similar to the concept of compound interest

Burnout in health care

Give the ones you love wings to fly, roots to come back, and reasons to stay.

Sustainability may be the most important and most challenging of goals for a team to achieve. Although most burn centers now produce outstanding clinical results, the current health care environment has made it more difficult to deliver value, in which providers are expected to increase the quality of their output while decreasing the cost of delivery. Health care systems are designed to focus on populations of patients, not necessarily specific patients, and the responsibility for value creation has drifted and shifted toward individual providers. Unfortunately, this combination of increased individual responsibility and decreased autonomy has produced an epidemic of burnout in health care providers, with a mismatch in supply of human capacity and demand of institutional needs. Burnout threatens not only the well-being of ourselves and our colleagues but also the health of our teams and, ultimately, the safety of our patients.

What is burnout, and is it real? Burnout is a clinical syndrome defined by 3 components: (1) emotional exhaustion, (2) cynicism and depersonalization (of patients, peers, and family), and (3) perceived lack of personal accomplishment. A recent systematic review of 46 rigorous, well-designed studies assessing the impact of burnout in health care providers found that poor well-being was associated with poorer patient safety and that burnout was associated with increased medical errors. The authors admonish, “This review illustrates the need for healthcare organizations to consider improving employees’ mental health as well as creating safer work environments when planning interventions to improve patient safety.” The fact that 300 to 400 physicians commit suicide each year—the equivalent of 2 graduating medical school classes and at a rate 3 to 4 times greater than age-matched controls—should be a wake-up call for all of us, that the health of our healers, our teams, and our patients is threatened and in acute jeopardy.

Current burnout rates vary by physician specialty, but data from the surgical literature indicate that approximately 40% of surgeons now meet clinical criteria for burnout. A 2008 survey of members of the American College of Surgeons found that academic practice was somewhat protective compared with private practice (37.7% vs 43.1%), and the authors suggested a partial list of contributing factors: length of training and delayed gratification, limited control of the provision of medical services, long working hours and enormous workloads, imbalance between career and family, isolation from colleagues, financial stressors, grief/guilt about poor patient outcomes, insufficient protected time for education, and increasingly inefficient work environments.

Even more alarming is the incidence of burnout in our surgical trainees, who will become the next generation of practicing surgeons, educators, and role models. A national survey of 695 general surgery residents actively engaged in clinical training in an Accreditation Council for Graduate Medical Education–accredited program, found that 69% of respondents met criteria by the Maslach Burnout Inventory for at least 1 of the subscales. Thirty-four percent scored positive for 2 of the subscales, and 10% of trainees scored positive for all 3 subscales. Multivariate logistic regression analysis indicted that the following independent risk factors were associated with burnout: older residents, female gender, early years of clinical training, career plans to enter private practice, increased work hours, and absence of a structured mentoring program.

Burn care providers have intuited the problem of burnout for years (if not decades), but little formal attention has been focused on studying the magnitude and scope of burnout in our community. Furthermore, the impact on the health of our teams remains speculative, but certainly, burnout cannot be a good thing. Studies assessing the incidence of burnout in plastic surgeons suggest a validated rate of 30%, with microsurgeons and aesthetic surgeons having the highest burnout rates. Burnout has not been examined in burn surgeons specifically, but the nursing literature indicates that although burn nurses may report a higher degree of personal accomplishment than their peers, burnout rates remain unacceptably high. Implications for the nursing workforce are similar to those of surgeons: increased medical errors, poor communication with family members, and increased staff turnover.