Podcast – High Performing Teams with Dan Dworkis at Tactical Trauma 24

Welcome to the St Emlyn’s podcast. I’m Iain Beardsell

and I’m Liz Crowe

And we are at Tactical Trauma 24 and it’s a huge delight to welcome Dan Dworkis to the podcast, an experienced podcaster himself from the Emergency Mind podcast which I’m sure many of our listeners will have come across and if not I highly recommend it but Dan, could you just introduce yourself to our listeners?

Yeah. Hey folks. so nice to meet all of you all as it were. My name is Dan. I’m from the States. I’m in Los Angeles. I’m an ER doctor by training and these days most of what I do is think about how individuals, teams and systems perform in moments of crisis and stress.

It’s been a real theme at Tactical Trauma to talk about team performance and how we get the best out of teams.

And hopefully over the next few minutes, that’s what we’re going to focus on. How do we get the best out of individuals and how can we make sure we’re doing the very best and striving for excellence? And I know Dan, that idea of excellence is a real passion of yours.

Absolutely. I think it’s worth taking that step back as we’re thinking about how teams perform and ask what we’re aiming at. Because a lot of times in medicine we conflate the ideas of safety and excellence. And when we talk about excellence or clinical excellence or team excellence, what we’re really saying is we don’t want bad things to happen. That’s how we tend to use it. And to me, I think it’s much more than that, right?

So, you can use this phrase, excellence is more than the lack of bad things to sum that up. I’m gonna go on a brief diversion and tell you a story about a rosebush, right? This comes from the positive psychology world and Martin Seligman is the one that I heard it from.

The idea is if you have a junkyard or a piece of land that’s full of dirt or rubbish or whatever, and you want to grow roses, it’s not enough to just clean up the stuff that’s there. If you take all the trash away, you don’t get roses, you get empty ground. If you want to grow a rosebush, you actually have to plant the seeds of a rosebush and then water it.

And I think excellence really works in the same way. A lot of times we talk about clearing the trash, getting people back to zero, to that empty ground, and we don’t talk about what it takes to go beyond that and to aim towards the highest level of practice that we could actually accomplish. So, I think that metaphor really hits in a lot of ways is your team looking at going to zero or are you really pushing forward towards something else?

Would you say that one of the major issues is that we are so insular? I’m working in a team in a hospital, we feel like we’re performing really well, our data maybe benchmarked against other people allows us to think that maybe we’re going really well, but how often do you think teams get out and look at other teams, go and visit other teams, see how they function, think, oh yeah, no, we actually doing this a bit better.

Actually, this is where we can improve. Apart from conferences, how else do we look at data in a very real way? And how do we get those real insights into that?

I think inherent in that question, it is really interesting and probably mostly worthwhile idea that you can measure some of these things, right?

Because if you have metrics that you’re looking at, we’re going to take the number of catheters associated infections to zero, we’re going to have door to balloon time be blah, blah, blah, right? These are all metrics that are helping us make sure that we’re playing the right game and we’re playing it at least as well as other people, which is really good.

But that doesn’t really answer your question which is what are we aiming at? So, part of it I think is you have to dream a little bit bigger than that. So, if you can sit down and ask your team, what does excellence look like to you? And really ask that question. How do we know that we’re performing at the best of our ability? And what does it look like for a team to push that boundary forward and be better tomorrow than you are today? And I’ll leave that as a breadcrumb because to me that’s one of the answers. Teams that are excellent, systems that are excellent, are devoted, fanatically devoted to being better tomorrow than they are today.

And that should be part of your language, that should be part of your system, that you’re looking back at what you did and actively evolving that line moving forward to it.

And I would say that is the big stumbling block because people like, wow, we’re doing so great, let’s just say exactly where we are.

And that’s not excellence. it’s I’m happy where I’m at, therefore, I must be excellent and I’m staying there, whereas, to be excellent, I love that you’re saying that it’s got to have a future focus and that we should constantly be pushing at that ceiling, shouldn’t we?

I think so for sure. And I think there’s a couple of yardsticks or meter sticks because we’re you know on this side of the pond right now to think about using for that, right? And one is the sort of relativistic local one So within our shop, within it with our set of resources and with our constraints, are we performing at the best of our ability. And then the second one is a more universal one which is compared to the best that anybody could do, how are we performing when we’re looking at that and how are we advancing those fields?

So, I worked for various periods of time at really small places You know I’d be the only doctor in the er or occasionally the only doctor in the whole hospital, and you have a really small team and what you can accomplish what excellence looks like in that scenario Is going to be a little bit different than say when I was practicing at Mass General when you have Every resource that you could possibly imagine. So, you need to ask yourself both of those questions. How are we doing compared to what the best any human could do in this situation, any team of humans? And how are we doing compared to what we did yesterday? Are we pushing those things forward? And you can make enormous improvements along both of those directions if you’re willing to ask those questions and sit with the answers to them.

Because they’re not always fun answers, right? They’re not always yeah, we’re doing great. Sometimes the answers are, you know what, we’re doing okay. And okay is what we accomplished today, but tomorrow, what are we going to do differently to it? And it requires that sort of fearless looking at it.

Talking to some of the delegates here, lots of the problems we see in the UK and around the world in emergency medicine are replicated in every country. And I’m sure you experienced that in the U. S. as well with many patients, not enough time. And a big theme of what I’ve been hearing is that we need to spend more time thinking about what we do. But sometimes you just have to get on and see the next patient and the next patient and the next patient. I know with your Mission Critical Team Institute, you’ve been doing some work around this, but what are the simple things that people in busy emergency departments can do when they’re time limited to make changes and support their teams?

So, we had this really busy shift the other day, and there were a lot of traumas, a lot of really sick people. We’ve been having a lot of problems fielding the CT techs to actually operate the CT scanners. Routinely there’ll be a deficit where we just actually can’t provide the level of care that we necessarily want to provide, or we’re, behind the time that we want to do it in.

There’s a lot going wrong on this shift, and we’re struggling, my team is struggling, everybody’s trying to do our best and there’s this really annoying sound going on in the background. And the sound is this one door, has become so rusted that every time anybody goes through it, it’s just this, and I won’t try to reproduce it on this podcast to spare our listeners, but it’s this shriek.

So, on that shift, we called the amount of maintenance and got some WD 40, and we oiled that door, and we fixed it so that the next team would have one less thing to deal with. Now, did that fix the underlying staffing problem? No. But that next team had one less thing to do, and they were better positioned than we were to do it.

So, if you adopt that, sort of you know from the Japanese concept of kaizen of constant and never-ending improvement, and you’re able to make that 1 percent change in Your universe around you. To me. I think that is part of the answer. So, there’s this leave no trace camping concept, right? You want to leave the campground as good or better than you found it when you got there?

So, can you practice that in emergency medicine? Can you go into your shift and leave that hospital and that shift better than you found it? Even if it’s just a little bit, and to me that like in addition to fixing the door, what that really does is counters the hopelessness of the situation, right?

Because it tells everybody around you, no, we actually can make a difference. We can make a difference every shift and you have a choice every time you’re going into those shifts. Are you going to adopt a sense of hopelessness where you can’t fix the problems or are you going to leave that shift slightly better than you found it?

So, James Clear in his book Atomic Habits says that habits are a vote for who you are, right? The small choices you make are a vote for who you are. So, I think everybody on every shift can vote for who they are and who they want to be as a team. And to me, that’s fixing the door.

And you’re talking about, the 1 percent marginal gains, and I always say to people, why don’t we just set up the next team for success in the best way that we can?

So even if you’re caring for someone who’s quite challenging, has been tricky the entire shift, I’m about to come off, you’re coming on, and I’m like, oh, guess what, Mr. Brown? You’ve got Dan looking after you! Like, he is like an amazing doctor, and Dan, I gotta tell you, Mr. Brown, he’s good at watching the clock, he’s unhappy if he doesn’t get his meds on time.

Dan, that’s super important to Mr. Brown, but Mr. Brown, seriously, you’ve just scored. it’s just a way of setting ourselves up, you can still say, watch it Mr. Brown’s tricky. like you can still say that behind closed doors. But it’s about creating this mindset for everyone,

 it’s chaos out there today. it’s going to be tricky. You’re not going to see all the patients. We’re not going to clear the board. But let’s just make a commitment for two things. Everyone that you see that is in front of you, they will have a good experience. They will be safe.

And at some point, someone will cover you, so you can go to the toilet and have something to eat. If we could just do that, surely that would make a difference.

I think so. And I think it’s worth saying out loud that’s not Pollyanna. No, that’s not saying everything’s great and it’s all roses and we should pretend that there aren’t these big problems going on.

We should address the problems that are going on, but nevertheless we can do it in a way that is forward thinking and that leaves the next generation better than we have it for it. I think that’s part of what excellence is. No matter what sort of a situation you’re practicing in. Yeah.

Can I just ask where you get your energy from?

All of this, and both you and Liz are very similar, I think. You’re positive people. You’re trying to get the best out of the shift. You’re trying to do the best you can. Some days I just find that really hard. I just find it hard to be positive. I know I shouldn’t admit it, but I do have you got any top tips about what you can do to change that mindset.

And we’re talking a lot about mindset, but that’s what this is about. How I can change my own mindset and go, okay, I’m gonna do my best today. Mr Brown matters to me. I want to fix the door. I want to make it better for the next people coming along, rather than I just want to get out of here.

I think that’s a really important thing, right?

 There’s a level of being out of tune, where what you need is to overhaul the instrument or the car or the engine or whatever it is. And that’s a conversation about how do you help yourself, and when do you need to take a step back and when do you need to find help and when do you need to get the resources that it takes to bring you back in the centre.

And then there’s a different conversation, which is a conversation about the active centering that might take place during a day or during a shift. And that conversation, I’m going to put bounds around it and those bounds are when you are not in danger, either you’re personally in danger or you’re so far out of tune that is a danger to yourself or others.

Right? So that’s a different conversation. There is no shame in getting help when you’re in that space. That’s what you should do. That’s what you need to do. I do therapy. I think everybody in this world should be doing therapy, if you’re exposed to these things and doing this kind of work, I think that it should be normalized as much as possible.

And I’m happy to say that out loud on a podcast. But let’s put that aside for a second and instead talk about what the everyday bit is in the middle there. So, Christina Shenvey, who’s a wonderfully brilliant ER doctor, talks about this idea that not every shift is going to be great, but can you raise the mean, and narrow the standard deviation?

Can you do this stuff so that on average, more of your shifts are doing what you want to be doing and you’re leaving more of them feeling the way you want to feel, and can you tighten it up so that there’s less of the truly horrible things going on? So, if you reframe it a little bit in that question to toss it back to you, I think you can get a different set of answers to it, right?

If instead of being like, today I have to do this. You can ask on average, I want to end most shifts feeling like this, right? I want to think about the integral of my success over time. I want that to be positive. I really want the world to have been a better place for me being here. I don’t think I get that in any one second. There are definitely times when I don’t feel like I’m performing at the level that I want to perform, or I’m living up to the best version of who Dan is but on the integral over time, I want to go to sleep every night knowing I’ve answered that question well.

I recently changed the way I think about this a little bit, right? After a conversation with Mike Tagman, who’s a, a brilliant EMS guy, and also a practitioner of Aikido, right?

it used to be that I thought about it as like a one-dimensional model of a string. so, there’s a certain amount of tension on a string. If you’re too tight, the string breaks, and if you’re too loose, you don’t get music out of the string. So, it has to be the right amount of tension.

And that was pretty cool, but after this conversation with Mike, I walked away with a more three-dimensional model for it. And the model is like gravity. So, there’s some centre of gravity that’s your centre and you’re orbiting around that. Now you might get knocked out of that orbit a little bit by whatever happens that day, but the skill is returning to that orbit and getting back to centre.

It’s not a place that you ever end. It’s not a place you ever land. Instead, it’s this constant circle and dance with the centre of gravity for it. And if you can think about it like that, then you understand that it’s not so much what happens in this exact moment. Although that’s part of it, it’s more of am I doing the right things to keep me around the space and in the area and around the centre of gravity that I feel I want to be at, which gets back to excellence because that’s up to you to define what that is.

I’m really reflecting on what you said because I think we need to be mindful because there’s different personality types and there’s different mindsets. And there are certain things that are in our realm of control and there are things that are out of our realm of control. And for me, personally, I try to remember that our patients are always having a worse day than us.

I have come to the hospital by choice. I’m being paid to be there. And it’s not to say that every day, like I’m skipping, but I genuinely try to think of things from other people’s perspectives. And I try to watch out for my colleagues. I try to be mindful, of people who might need to tap out, like who might need to go and do something else for a while and not see that as failure, or not see that as the end of the career, or a change of career is also not a failure.

I think that the biggest thing for me though, is that I constantly see people in health saying what is wrong with me when there is something terribly wrong with the system. We are struggling to survive in a system that is making it more and more difficult for us to do the things that we love.

There’s more bureaucracy, there’s less resources, there’s not enough time to spend with patients as people would like to. But I guess, rather than every day saying, the system is broken and I’m exhausted, the system is broken and I’m exhausted, that’s never going to be energizing, I try to just reframe that a little bit to say, the system is broken, and today these are the things that I can change and make different for myself, for the team, and for me most importantly, for the patients.

Yeah, I think that internal locus of control is incredibly important, right? Are you doing the things you can with what you have? I think that’s part of the metric of excellence, right?

Are you doing the things you can with what you have?

Dan, we’ve mentioned the Emergency Mind podcast, that I’m sure people will be going to download and listen to now. You’re also the Chief Medical Officer of the Mission Critical Team Institute. I think part of the thing I’ve learned from this conference is that lots of people are doing lots of amazing things that I probably never knew were happening. Just tell us a little bit about that.

 So, the Mission Critical Team Institute, exists to work for and to serve the success, sustainability, and survivability of folks operating in mission critical teams. That triple mission is really important, right? The success, sustainability, and survivability of those people.

And what that incorporates is a lot of the allied special forces community, The, urban and wildland firefighters, aerospace and teams in medicine, emergency critical care, stuff like that, right. All these folks that have to perform at an exceedingly high level in these life-or-death moments, these complex, rapidly adaptive problem sets that we fight against.

We were spun up at the request of the special forces community, and now we build these cross-connecting branches between these groups, to think through how teams and systems perform under pressure.

 Dan, thank you so much for joining us today on St. Emlyn’s, it’s been an absolute pleasure. I’ve learned so much from you.

Thanks, Dan.

Thank you all so much.