Dr. Brian Goldman: Leaning into Uncertainty
Medicine has become too complex to enable clinicians to be solo operators. In his book The Power of Teamwork, Dr. Brian Goldman explains that having a diversity of thought in healthcare has made moving from ‘I Alone’ to ‘We Together’ a necessity.
Our guest Dr. Brian Goldman is a longtime staff physician at Sinai Health System, and a podcaster – host of White Coat, Black Art on CBC Radio One and the CBC podcast The Dose. He’s also the author of three books.
Many people who read his most recent book The Power of Teamwork have an ah-ha moment when they realize that they’re not actually working on a team but a group. As Brian explains, many teams flounder because the members of that team are more focussed on individual goals than team goals, they haven’t had much input in setting those goals, and they don’t help one another.
Whether it’s in healthcare, the military, aviation or a corporate environment, for real team problem-solving to happen, Brian says everybody must feel safe to say what they see. That means breaking down longstanding hierarchies, taking chances and leaning into uncertainty.
Mentioned in this Episode
- Sinai Health System
- White Coat Black Art
- The Dose
- Alexa Miller - Visual Thinking Strategies
- Dr. Joel Thorp Katz
- Emily Mathieu
- Erin Byrnes
- dotMD – A Festival of Medical Curiosity
- Dr. Trevor Jain
- The Spy Who Knew Too Much by Howard Blum
- The Ezra Klein Show
- Dr. Teodor Grantcharov - The OR Black Box
- David N. Titcher
Imagine you could step inside the minds of Canada's healthcare leaders, glimpse their greatest fears, strongest drivers and what makes them tick. Welcome to Healthcare Change Makers, a podcast where we talk to leaders about the joys and challenges of driving change and working with partners, to create the safest healthcare system.
Welcome To Healthcare Change Makers, a podcast produced by HIROC. I'm Ellen Gardner with Michelle Holden and Philip De Souza. Our guest, Brian Goldman, is a longtime staff physician at Sinai Health System and a podcaster, host of White Coat, Black Art on CBC Radio One and the CBC podcast, The Dose. He's also the author of three books.
Many people who read his most recent book, The Power of Teamwork, have an aha moment when they realize that they're not actually working on a team, but a group. As Brian explains, many teams flounder because the members of that team are more focused on individual goals than team goals. They haven't had much input in even setting those goals and they don't help one another.
Whether it's in healthcare, the military, aviation, or a corporate environment, for real team problem-solving to happen, Brian says everybody must feel safe to say what they see. That means breaking down longstanding hierarchies, taking chances and leaning into uncertainty.
Ellen: Welcome, Brian. It's great to have you on Healthcare Change Makers. Congratulations on your book, The Power of Teamwork. It's just a great read. Near the beginning you talk about the importance of asking questions and follow up. And I know from experience the phrase, tell me more, usually opens up a whole new line of thinking, but most people don't do it. In fact, most people don't ask enough questions and if they do, they don't follow up. So how can we teach people to get better at asking questions?
Brian: I'm so glad that you've started there. I'll answer your question, but I also want to back up and highlight what I think is the core issue that what keeps people from asking the question, tell me more. Tell me more is all about leaning into uncertainty. And I imagine that somewhere in the implicit rules of being a leader is the phrase or the admonition to eradicate or stamp out or minimize uncertainty. And I think there's many reasons for that, but one of the big reasons I think in healthcare is that we tend, and I'm still a practicing emergency physician, I think we tend to be in a hurry. We operate as if we're in a hurry.
I'm finding that as I get older as an emergency physician, when referring physicians are on the phone and I'm dictating, I'm scribbling notes about why they're referring a patient to the emergency department, they talk fast, everybody talks fast. Everybody wants to cut to the bottom line, get to the answer quickly. Let's move on from this meeting. And that is death to a team meeting. And so, Ellen, what you're asking is a really profound question.
First thing we have to understand is that we have to accept uncertainty. And of course, HIROC should be very concerned about this because we all know about cognitive errors. We all know the many reasons for cognitive errors that lead to mistakes, that lead to hospital disasters, and disasters by medical errors, that we hate uncertainty so much that we prematurely close conversations.
It's never either, or; either we lean into uncertainty or don't. You can have a mixture of both. You can practice uncertainty by just sprinkling a bit of it in there. Just hold on. Just pause for a second if you're about to say let's close this discussion off or table it for another time.
To ask questions, tell me more. What do you see that makes you say that? And then when that person has had an opportunity to say what they see, ask the rest of the group, what more can we find? And by doing that, I guarantee you, you're going to have a better result.
Ellen: Raising the issue of uncertainty is huge because I think that's the intimidation factor and why a lot of people, whether they're in a healthcare environment or a corporate environment are scared to speak up or ask a question. You talk about that yourself in your own healthcare training, how you answered a question once and were completely humiliated. So, I can see how it would be very difficult to get people to be open to even raising something that's a little bit, yes, out in left field.
Brian: I guess the first thing we want to engender, I think, when it comes to teamwork, if you want to get to team cognition, team problem-solving, and I think teamwork is necessary for any endeavour inside or outside of healthcare that's complex and patients are complex. We're all recognizing complexity as a major part of what we do, so you want to be able to engender that.
So you want to have a situation whereby everybody who is identified as being on the team, either the core team, the people you work with, and often including the broader team of people who work on those other silos that we often don't talk to and don't listen to, or they don't listen to us and we don't listen to them because we're pursuing our own agendas, you want to create an environment where everybody feels safe to say what they see.
That means to give us the benefit of their observation. From my standpoint, this is what I see. It could be, I see that this treatment plan that's been developed in the last 10 minutes has a flaw in it. It might be a medical student saying, you know what, the potassium is supposed to be elevated and I just looked at the chart and the potassium is actually low. I don't understand why that is. If you don't want to know that there's a problem there, then you're the problem. Because the whole point of risk management and quality control, quality improvement, continuous quality improvement is to ferret out mistakes. And the only way you're going to ferret out mistakes is by discovering them.
Philip: This is Philip here, and I think even your first response, Brian, it had so much to unpack. I feel like that you covered off probably three or four of Ellen's questions! But I wanted to dig deeper into the point about leaning into uncertainty, and you're absolutely right. I feel like we are in a sound bit culture. We want to hear one thing and next, move on. You're absolutely right there. But in your experience, is there one thing people could do to lean into that uncertainty so that people feel comfortable? I think we all know in healthcare, things sometimes could move slowly. So, to get people on board, is there something you do with your team or you've done, just in your years of working in healthcare, that you do to help others and yourself lean into that uncertainty?
Brian: I think that team leaders play a paramount role here. I think what they need to do is just change the meeting, change the nature of the meeting. I've had meetings off-site, I think that works. Basically what I learned from Alexa Miller. The whole concept of Visual Thinking Strategies I think has really changed my approach because I not only use that, I'll sometimes take the group to look at art. And by the way, you don't have to go to an art gallery to look at art. There's works of art in many hospitals. You can just take them down to the hallway where there's works of art and just ask them those questions. What do you see? What do you see that makes you say that? And what more can we find?
But you want to get from that to a clinical problem and immediately show the application, because I think it has tremendous application. That's why I wrote about that. I talked about Dr. Joel Katz taking students who have just been to the art gallery, and he takes them to the bedside of the patient and asks the same questions. It gets better results.
There is another thing that you can do and that is just to practice the improv technique that I talked about in the book called ‘Yes, and…’. So somebody suggests an idea and somebody else in the group immediately says, we tried that last year and it didn't work, or I can cite 10 papers to say why that won't work. That has the effect of shutting down that person and making them feel foolish. Instead of doing that, say ‘Yes, and…’. That means accept what that person has said and try to build on it.
Ellen: Brian, what was amazing in your book was how your journey took you to so many different realms – art, theatre, music, games, the military. You've just alluded to some of those experiences now and all the incredible people that you met and the different points of view and how it changed your whole philosophy around teamwork and around what needs to happen in healthcare. Did you know the journey was going to take you in such amazing directions when you started on this project?
Brian: I never know where the journey's going to take me when I set out to write a book. It took me to some amazing places and this gives me the opportunity to shout out the members of my team. I recognized early on that the only way I was going to write this book about teamwork was to assemble a team. And there was a larger team, but the core members of the team were Erin Byrnes and Emily Mathieu. They're both journalists, they're both working journalists.
I thought that the best way to tell the book, I wanted it not to be identified as an obvious management book. I didn't want it to be about management theory, there are lots of books like that. I wanted it to be a storytelling medium.
I work in something called creative nonfiction, so what I try to do is tell stories. It's the same thing that I do on my radio show on White Coat, Black Art. What I try to do is paint a picture of what the room is like and give people reading the book a sense that they're in that room. So, I wanted them to help me dig out some wonderful stories.
And if you read the lengthy acknowledgement section, you'll know that I did not come up with all of these stories. To me, the Rosetta Stone was meeting Alexa Miller at dotMD 2019 and eventually forging a friendship with her. I think she's terrific. I think the world of her and I think Visual Thinking Strategies really deserves a much stronger public airing. And I hope the book helps to get that.
Michelle: Hey. If you're a regular listener of our show, you'll know that we don't really do ads, but I promise this one is worth it. So please excuse this interruption to your car speaker or earbuds as I let you know that registration is open for the 2022 HIROC conference. This year's event takes place from October 17th to 19th. If you can't wait that long, when you register for the HIROC conference, you'll have the option of signing up for a special virtual tour of FM Global's research campus on October 12th. This one's for all the property and facility enthusiasts out there.
Our conference theme this year is all about looking forward and doing it together, Future Forward Together. Subscribers can look forward (see how I did that there?) to three days of fast paced, virtual learning. We've got an agenda packed with change makers in the healthcare space and beyond. And as always, our event is complimentary for HIROC subscribers. We placed the link to register in the show notes for this episode, or you can find it on all of our socials. We can't wait to see you there.
Ellen: One of the things that you talk about is flattening the hierarchy to encourage a diversity of thought in the team. And yet that does set up a little bit of a contradiction because you do need strong leadership on a team. So I'm thinking about one of the crises you talked about, the Swissair disaster, when they had to set up a temporary morgue in Shearwater, Nova Scotia. And Trevor Jain, he came across as such an amazing leader. And yet he never said you have to do things my way. So in your view, Brian, what qualities made him a strong leader and that leaders can demonstrate without being so authoritative and considering that you should be flattening the hierarchy?
Brian: Yeah, Trevor Jain was an important person to meet. He's an incredible physician. Trevor Jain came to that experience with the right skillset at the right time. He had pathology experience. He had worked as a pathology assistant, had been paid first as a volunteer. And then he was paid as a pathology assistant at a local hospital in the Annapolis Valley. That gave him the experience and information that he needed to set up one autopsy suite and then ultimately 12 autopsy suites. And nobody else in the room had that. Nobody else in the hanger had that when he arrived the day after the Swissair 111 disaster.
He had his experience as a member of the Canadian Forces Reserve. He had military leadership experience, but he was an exceptional, and he is, an exceptional leader within the military. He is somebody who explained to me the principles of team leadership in the military, the core ones. They are – knowing every member of your team, knowing something about their background that tells you what their strengths are. You have to know their superpower, because you have to position them to function on a team that brings out the best in them, that doesn't keep asking them to do what they're not best at. And to do that you have to move the pieces around, so you have to see how things fit together. Once you know their superpower, you have to know their vulnerabilities.
One of the things I found really touching about Trevor Jain was that at those moments when they had the unfortunate task of having to identify the remains, the DNA remains, the tissue remains of infants and children, and there were infants and children on Swissair 111, he made certain that the people who were conducting the autopsy at that point were not parents of young kids, which I thought was such empathy. It was such a demonstration of empathy. That's another thing, so he had empathy.
One of the reasons why he had empathy, and I wrote that whole other book, The Power of Kindness, and in that book, I was looking for the most empathic and kindest people on the planet to tell their story and then ask how they got that way. One way you get that way is by being downtrodden yourself, knowing what it's like to be put down, ignored. And as I talked about in the book, Trevor Jain is a BIPOC physician who knows what it's like to have been bullied, and in fact, harassed and tortured. He was beaten as a teenager. He had his homework stolen from him, ripped up. And that gave him tremendous empathy for anybody in the room who might have an opinion, but would be afraid to ask or would habitually not be canvased, not be asked their opinion.
And that included a maintenance worker in the hanger who he encouraged to be part of the conversation. This person was very reluctant to speak up. But once he encouraged them, he never looked back and this person became a member of the team. So those are some of the attributes that Trevor Jain brought to team leadership.
Ellen: One of my observations coming out of the book was that many of the people you talked to had trained in two very different realms, a car mechanic becoming a doctor, a doctor becoming a pilot. And of course I thought of you because you've always had different and concurrent careers as an ER doc, a journalist, and now recently as a podcaster. And I'm sure this is something you've thought about, but do you think having a foot in different careers teaches us more about operating effectively in teams?
Brian: I think it does. In the book, I talked about the value of this crossover wisdom, that people should seek out the advice of those who are not in their own domain, in their own silo. If you find people in your own silo or you know you're in a silo if you tend to see the world as insiders and outsiders, in groups and out groups which we do naturally, but that's a stress response. That's a response to feelings if you're under pressure, under stress, nobody understands us like us.
Certainly, reflecting on my own career, I knew nothing about empathizing with patients until I became a medical journalist and started telling stories on the radio of patients, what it's like to be a patient, what it's like to be a family member of a patient in the culture of modern medicine, and what it's like to be on a gurney or in a hallway for four or five days. Like a lot of us in healthcare, we tend to walk past those patients without considering what it's like to be them.
On a more elemental level, I learned to communicate. I learned how to communicate to patients in a way that didn't diminish what I was saying, but made it easier to understand. And part of that is decades of experience as a medical journalist, you don't use jargon. Jargon is often a dodge for communication. You just use common words that people can understand. The highest compliment people can tell me when they listen to me, is that they feel as if I've taken them into the world of medicine, to my side of the gurney, and they understand more than they did before.
For me, the variety, being able to bounce from one realm to the other has certainly sustained me. And to me, it's one of the things that immunizes me from burnout.
Ellen: So you have a podcast, two, in fact, The Dose and White Coat, Black Art, you've written three books now. You continue to work as an ER doctor at Mount Sinai and you have a family. So the obvious question, Brian, is how do you do it all? You must be busy all the time.
Brian: I am, and I'm busier than you think. I've been dealing with a close family member who has early-onset dementia, and I've become that person's caregiver. And I've entered into, to me, an undiscovered country of guardianship issues and discovering just how difficult to become the power of attorney, as recognized by a financial institution. If you aren't the power of attorney, becoming one on behalf of somebody who has dementia, who can no longer sign documents, presents its own challenges. And then there's getting to the point of personal care, providing some degree of personal care.
So how do you do it all? So I have a greater sense of crisis now than I've had in earlier parts of my life. Although there are times when, not to be overly dramatic, I was an emergency physician, I probably thrive on crisis. But even I have had to come up with some rules for coping and I've come up with three or four of them. One of them is perfection is the enemy of good. Now I didn't invent that phrase, Voltaire invented that phrase and I've had to learn to not be a perfectionist. And at the end of the day, I ask myself, are things better from my involvement? And if they are, then I say, good, you did a good job.
You can't do everything. And one of the things that I've learned how to do is to observe closely the things that I hate doing, or I can't do, the things that are the most soul-destroying tasks, and I try to hire somebody to do them on my behalf. Or I recruit somebody, beg, borrow, or steal, find somebody to do them instead. And the third rule is don't drown in their sorrow. If you are trying to take care of somebody who's in the midst of a crisis, you've got to take care of yourself. And emotionally, that means you have to find ways to take care of yourself.
And I discovered a fourth rule along the way and that is embrace the power of teamwork because without teamwork, you can't do this. You can't build a bridge. You can't build a nuclear power plant or a submarine or a brand new opera centre. You can't create a volunteer activity like Habitat for Humanity without a team. And you can't take care of somebody who can't take care of themselves without that. You can't be a parent without embracing a team.
Ellen: Right. Well, one of the stories in the book that really struck me was when you talk about the military and how one of the military people you profiled had ventured into healthcare and discovered one of the prime things they do in the military is they look after their people. That’s making sure they're well rested, they're well fed. Healthcare doesn't seem to do a good job of that, looking after people.
Brian: What is that all about? When Brian Ferguson said that, it was like, God, he's right. It's grueling to see if you can pass the threshold for self-immolation and for masochism. But once you pass that trial by fire, they take care of you. Whereas here, we make it an ongoing thing and almost a badge of merit. I did a night shift a couple of days ago when I was called in two hours early, because it was really busy, because we’re going through a really hard time, emergency departments right across Canada. And my first instinct was to talk about it triumphantly as a badge of honour. I got called in two hours early. 11 o'clock shift, I was called in at 9:00 PM. That's not a badge of honour. That's terrible.
The fact is that I still had to do my job. Although I have to tell you that the person I handed over to at nine o'clock the next day was, I'll name him, Dr. Sean Hardy. What a great guy. He's young enough to be my kid and he's one of the newest hires in our group at Sinai Health System. And he said, I'm going to make sure that whatever you need to hand over to me so that you can go home and get to sleep.
I guess what I'm saying is we know what we need, but we find it really hard to extend it to one another. And let me talk about nurses. I mean, nurses really feel starved for respect, affection, appreciation of what they do, and they're voting with their feet. And if we don't see just what a crisis that has visited upon us right now, then you can see that there's some system-wide issues. Maybe some of them are political, the political will to deal with, to take care of the core issues. And that's going to require some teamwork as well.
Ellen: You talk about this in the book and you have alluded to it in our conversation. How has learning about teamwork, really diving into it and writing the book moved you from being a solo act?
Brian: From ‘I alone’ to ‘We together’, I had to overcome. I can certainly appreciate as patients have become more complex that I savour those moments when I'm working with a nurse practitioner in a dyad, which is this two-person team, which is the smallest team and we're kicking around ideas. And I appreciate that. There's a particular nurse practitioner I worked with the other day on that night shift. It wasn't all night. It was just in the first two hours. And I really appreciated how she, Carrie, Carrie Kan, she also happens to be a flight attendant. So maybe she gets this in a way that other people don't that we enhanced each other.
I firmly believe that medicine has become so complex that there is no I alone anymore. We can't understand everything, know everything. I've discovered that I work better in an environment where I can be prompted. In resuscitations, nurses prompt doctors all the time. Oh, wasn't he allergic to that? Oh, I thought he was allergic to that. Oh, sorry. Thank you. Or a nurse says I haven't seen it done that way before. That's nurse speak for, don't do that, Dr. Goldman, because that's the wrong way to do it. And if you're smart, you pick up the hints and that's teamwork. That's what teamwork's all about.
Philip: One more question I have for you. You talked about ... and I really like that Ellen bought it up about the crossover wisdom and that's something Ellen's taught me and we practice that a lot at HIROC as well. I know my personal team, we do that as well. We do talk to other people from outside of the sectors. We learn lots of seeing things through a new lens. Is there some piece of really interesting ... I guess something that really helped you where you learned something that's not usually done in healthcare, but you learned it from outside of healthcare?
Brian: Alexa Miller and Visual Thinking Strategies.
Philip: Oh, okay.
Brian: That completely turned me around because I instantly saw the application at the bedside and in the resuscitation room and in the operating room. If the central story in the book, the core story is the story of Elaine Bromiley who can't intubate, can't oxygenate or can't intubate, can't ventilate, and it was unrecognized. It went unrecognized. Two nurses recognized it. One said we reserved a bed in the ICU. This is a patient who was supposed to go home from routine surgery in two hours. They don't go to the ICU. And then a second nurse said, I brought the surgical airway in. If one of those three, two anesthetists and one surgeon, had said, what did you see that makes you say that, that made you bring this tray in? Well, the oxygen saturation is at 42% and it's been at 42% for the last eight minutes. Then there might have been a different outcome that day. So yeah, Visual Thinking Strategies. That's mine.
Philip: Very good. I'll pass it back to Ellen for our closing.
Ellen: Well, the final part of our interview, Brian, is the Lightning Round. We just ask you a few questions and just tell us the first thing that pops into your mind. What's the most interesting thing you've learned from a book recently?
Brian: From The Spy Who Knew Too Much, that a mole could exist in the Central Intelligence Agency planted there by the Soviets and functioned there for 20 or 30 years. And the people, the higher ups at the Central Intelligence Agency at the CIA erected barriers to discovering who the mole was, some of them unconscious.
Ellen: What's one thing we can't guess from your LinkedIn or your Twitter profile?
Brian: That in a parallel universe, I was a Hollywood screenwriter.
Philip: What? Wow. I want to know more about that book. Ellen, you continue.
Ellen: Outside of your own, of course, Brian, what is your favorite podcast?
Brian: The Ezra Klein Show. It's my deep dive show when I go on a long run. It's been harder these days, because I broke a bone in my spine about nine months ago. It's healed, but ... Well, it hasn't healed, but it's a little spicule of bone, but yeah, the Ezra Klein show because he deals with uncertainty. Ezra Klein is a great interviewer and he's well-read and he takes you deep into some of the most important issues going on culturally in the United States. And politically, they have threats to democracy. Roe V. Wade was overturned and there's the rise of populism, but occasionally he interviews sci-fi writers too, which I think is great.
Ellen: Thanks for that. A company whose culture you really look up to.
Brian: I'm going to get the name of the company wrong. It's Teodor Grantcharov’s company. It's the company that developed the OR black box. It's an open concept company... it's a fairly flat hierarchy. Teodor Grantcharov set it up that way so that he would have outsiders talking to each other. He would have computer programmers, artificial intelligence experts, deep learning experts, being able to talk to surgeons and talk to residents and nobody's afraid to say what they see.
Ellen: I'm going to ask what's the best piece of career advice you've received, but also what is the advice that you give to other people when it comes to their career?
Brian: Catch yourself liking something or not liking something. In other words, don't just run to get past the moment, but catch yourself saying things like I hate this, I can't stand this, or I really love this, and use that as a guide for what you should pursue.
Philip: I like that a lot. I like that. I'm going to use that. But back to the Hollywood thing, I always wanted to ask people who work in healthcare. Obviously everyone watches TV, I'm assuming, and movies, and there's this show called New Amsterdam. I don't know why I like it. I like it so much. In our team, we always wonder what do people who actually work in ER, in a hospital, what do they think about a show like New Amsterdam? Have you watched it, Brian, or have you seen it before?
Brian: You know what? The topics are so earnest and they're so close to the things that I do on my radio show. I'm looking for total escapism and right now I'm watching The Old Man. The Old Man is Jeff Bridges and Amy Brenneman. It is just a tour de force. I like to watch all the Star Trek series and fortunately there are a number of Trekkies amongst my friends in emergency.
Philip: And I don't know if you're allowed to say, but when you dabbled in screenwriting, was it a specific something that you're passionate about that you were writing about?
Brian: I wrote a script that never got produced, and it was about a series of murders taking place in a hospital. I wrote a specs script for Star Trek: The Next Generation, because my cousin, David Titcher, David Nathaniel Titcher, who did the remake of Around the World in 80 Days, the Jackie Chan film. He wrote that script. That was probably his most famous script. He had an agent and the two of us ... he was able to get that script in there. Of course, it didn't get produced. Although I swear that I saw a scene that beat for beat was my scene. And they sometimes referred to those rejected specs scripts as the slush pile, and they would grab scenes. That’s fine. I work in the business. If you worry about that, then you shouldn't be in that business. And that's not because I think that people steal your work, but because I don't believe that ideas are that original, that there aren't that many original ideas.
Ellen: Well, the satisfying thing is doing the writing, not so much expecting to be produced, right?
Brian: It's the process, exactly. If you don't enjoy the writing, then the result will not please you, or the outcome, the success of it will not please you.
Ellen: Well, more proof, Brian, of the diversity of your career and your life and how much richness that has brought to you. So just a great conversation. Your book, we could have gone into so many different areas, but you gave us just wonderful ideas on, yes, the importance of teamwork and having empathy and being leaders that care about our people and finding their superpowers. So, thank you so much for coming on our show.
Brian: Well, thank you for having me and thank you for giving me a chance to talk about teamwork, and this was a great conversation. I enjoyed it.
Ellen: You've just been listening to our interview with Brian Goldman, staff physician at Sinai Health System, host of White Coat, Black Art on CBC Radio One, and the CBC podcast, The Dose. For more information about HIROC and to listen to past episodes of Healthcare Change Makers, go to our website, HIROC.com. Thank you for listening.
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