The difference between teams and groups of individuals is relevant to every orthopaedic surgeon because it is through teams that patient care is delivered. This is not a new concept, but it reflects a paradigm shift for surgeons indoctrinated to regard the "team" as a mere support system for individual accomplishments.

As surgeons, we share an inclination to tightly control processes and to view our teams as vehicles for our individual efforts. Ultimately, we bear accountability for a technically successful surgery and objectively satisfactory outcome. We alone, it often seems, answer to our patients—not our teams.

But the evidence that teams uniformly provide better outcomes than individuals is indisputable. Shared vision and accountability, mutual support, and diverse input result in synergies that give teams an advantage. Indeed, business consultant Patrick Lencioni (The Five Dysfunctions of a Team: A Leadership Fable) states that teamwork remains the one sustainable competitive advantage that has been largely untapped.

Getting started
In Good to Great: Why Some Companies Make the Leap…and Others Don't, management researcher Jim Collins advises leaders "to start by getting the right people on the bus, the wrong people off the bus, and the right people in the right seats." However, surgeons may have no hand in assembling our teams, infrequently work with the same team, or may be placed on a team seemingly filled with difficult personalities or mediocre competencies. While our willingness to shoulder our responsibilities are laudable, our ethos as surgeons may potentially disadvantage us as collaborative team members, despite our individual competence and experience.

In a recent contribution to AAOS Now, Jason L. Harwood, MD, and Jeremy M. Burnham, MD, acknowledged that "it is no longer enough to be just a skilled surgeon in the operating room," and that "it takes a different set of leadership skills to lead today's interprofessional team than was required of the surgeon of yesteryear." Here's the lingering challenge—we may spend little (if any) time auditing how our teams are performing, have insufficient awareness of barriers that compromise team effectiveness, and have underdeveloped leadership skills to effectuate team development.

Highly reliable teams must have an effective modus operandi—norms of behavior—not merely competence and clarity regarding responsibility and objectives. Health care is replete with checklists and process requirements to ensure quality and safety, but a high performing team—a synergistic team, for which the "total is greater than the sum of its parts"—must also share an esprit de corps. This emanates from relationship equity and mutual trust.

Building trust
A sense of fellowship and friendship with members of a team develops over time. All too often, however, this necessity may be unrecognized or undervalued, and, as a consequence, not developed. Despite the application of safety and performance initiatives such as Crew Resource Management, popularized in the airline industry to minimize preventable error and to manage its consequences, and TeamSTEPPSTM, popularized by the Department of Defense to highlight fundamental leadership, communication, and monitoring processes, attaining team synergy requires more than mere adherence to process improvements. It requires deliberate attention to how we interact with our teammates.

In many situations, we may be so focused on the tasks at hand that we may be unaware of the impact of hidden, unresolved feelings between and among members of the team. Unrecognized bias or misunderstanding of context may lead to inaccurate assumptions about individual behavior, eroding trust, compromising communication, and prohibiting conflict resolution.

Ideally, highly performing teams are self-managed. Any member can exercise leadership by creating the conditions for team effectiveness. Collaborative leadership must include a balance between reflective inquiry and advocacy. The modus operandi must include practices that stimulate information exchange and processing, rather than strict directives for a particular outcome.

The command-and-control style many of us learned is riddled not only with the potential for error, but also with the disempowerment of other team members. So how can we tell if our team is more than a group of individuals?

Daniel Goleman, best known for his research on emotional intelligence (EQ), advocates that we be keenly aware of the "emotional reality" of our team. What are the norms of behavior? Are feelings acknowledged, and do they matter? Do team members hold each other with unconditional high regard? When differences of opinion arise, or behavior appears impatient, uncooperative, or temperamental, are assumptions made, with a rush to judgment, or is there an underlying commitment to understand what is driving the behavior so that potential unrest can be vetted and addressed?

Limited visions?
In my evolution as a good teammate and collaborative leader, I realized that my focus on what I was doing—the surgery—limited my vision of the landscape—the conditions in the rest of the room and the emotional reality. I am certain that my limited awareness and extreme focus may have been perceived as controlling, and my lofty expectations of others as ingratitude and inflexibility. My attentiveness to detail and fear of personal failure may have been interpreted as intolerance of mistakes and insensitivity to feelings.

Not until after I became a master instructor in TeamSTEPPS did I fully appreciate that the root cause of suboptimal team performance is not necessarily failure to adhere to well-accepted process improvements, but an under appreciation of how important relationships and connections are to team dynamics. Process improvements and/or mandates alone are insufficient to create true team synergy. Team members are not programmed computers that come to work each day with singular resolve, unfettered by life's complexities. Team dynamics are fundamentally based on relationships, trust, and affection. We must constantly monitor how we perceive one another and never stop calculating whether our conduct builds or erodes trust. Trust enables conflict resolution and honest dialogue.

How can we as orthopaedic surgeons improve the emotional reality of our teams—particularly when we may work infrequently with the same team members or when personalities don't seamlessly gel? Becoming more mindful is key. Mindfulness has three aspects:

• Attentive observation—the ability to see what is happening without prematurely making judgments that might diminish our capacity to understand
• Beginner's mind—taking a fresh perspective on a familiar problem rather than being biased or rigid
• Presence—being there physically and emotionally

As surgeons, we may be challenged to reveal our vulnerability, to ask for help, solicit input, or to express an awareness of the stress we may feel or the fears we may understandably have on behalf of our patient. But expressing vulnerability to one's team builds trust.

Becoming collaborative leaders
How do we develop as collaborative leaders? It begins with modeling our own EQ. EQ involves self-awareness, self management, empathy, and the ability to make connections with others to optimize outcomes. We must model these skills in such a way that other members of the team also become aware of their value.

Effective leadership in the context of a team requires that we regularly ask for feedback, to more fully understand and appreciate others' perspectives and behaviors. If teams are to practice and develop together, growth and learning require a process that explores conflict without judgment or bias, and resolves differences through respectful inquiry, listening, empathy, and dialogue.

Our expertise and intellect may have gotten us on the team, but our influence emanates from our temperance, equanimity, empathy, and humility. We must resist a control-or-give-up mentality amid challenge or conflict. We are either part of the problem or part of the solution.

We need to vigilantly monitor our team's emotional reality, and inspire collective action when mistrust, poor judgment, lack of mutual respect, poor self-awareness, and flawed self-management—to name a few potential saboteurs—interfere with conflict resolution. Improving our own EQ may begin with a heightened awareness of our frustrations and stressors, so that we can more effectively manage our reactions and responses.

Empathy fuels a commitment to understand what drives others' behavior, and engagement underlies a deep appreciation that connections with our team members build trust. Our mood, sense of optimism, and actions create our reality. In the final analysis, we will be rewarded when we work as a team rather than with a group of individuals.

Matthew M. Tomaino, MD, MBA, is in private practice at Tomaino Orthopaedic Care for Shoulder, Hand, & Elbow, in Rochester, N.Y.

References:

1. Lencioni P: Overcoming the Five Dysfunctions of a Team: A Field Guide for Leaders, Manager, and Facilitators. San Francisco, CA, Jossey-Bass, 2005.
2. Collins, J: Good To Great: Why Some Companies Make the Leap and Others Don't. New York, NY, Harper Business, 2001.
3. Harwood JL, Burnham JM. Leadership: A personal journey. AAOS Now September 2015. Available at http://www.aaos.org/AAOSNow/2015/Sep/youraaos/youraaos4/. Accessed December 8, 2015.
4. Goleman D, Boyatzis R, McKee A: The emotional reality of teams. J Org Excel 21(2), 55–64. http://onlinelibrary.wiley.com/doi/10.1002/npr.10020/abstract. Accessed on December 8, 2015.
5. Epstein RM: Mindful practice. JAMA 282(9), 833–839. Available at http://www.ncbi.nlm.nih.gov/pubmed/10478689. Accessed December 8, 2015.
6. AAOS TeamSTEPPS Training: Available at http://www.aaos.org/CustomTemplates/Content.aspx?id=22433. Accessed on December 8, 2015.