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We explore the evolving dynamics of health care teams with guests Matthew Sherrer, an anesthesiologist, and Brooke Vining, a nurse anesthetist. We discuss the shift from traditional team structures to a “teaming” mindset, the challenges of building trust in rapidly changing environments, and the impact of professional politics on patient safety and clinician wellness. Matthew and Brooke share their insights on fostering psychological safety, overcoming role ambiguity, and promoting a culture of curiosity, passion, and empathy in the high-stakes world of health care.
Matthew Sherrer is an anesthesiologist. Brooke Vining is a nurse anesthetist.
They discuss the KevinMD article, “Care teaming: a new paradigm for anesthesia care teams and beyond.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Matthew Sherrer and Brooke Vining. Matthew is an anesthesiologist. Brooke is a nurse anesthetist. Together, they wrote the KevinMD article, Care Teaming: A New Paradigm for Anesthesia Care Teams and Beyond. Matthew and Brooke, welcome to the show.
Matthew Sherrer: Thank you for having us.
Brooke Vining: Yeah, thank you.
Kevin Pho: I’ll ask each of you briefly to share a quick word about yourself, your story, and your journey. Matthew, why don’t you go first?
Matthew Sherrer: Yeah, I am an anesthesiologist at UAB here in Birmingham, Alabama, my hometown. I spent 11 years in private practice here in Birmingham and then made the jump over to academics five-plus years ago. I’m really enjoying the ride here at UAB.
Kevin Pho: Perfect. And Brooke, you’re a nurse anesthetist. Tell us a little bit about your story.
Brooke Vining: I am. I’m a nurse anesthetist. I’ve been at UAB since 1998, so I’m in my 26th year. I’m really excited to be in my current position as the Associate Vice President of Preoperative Services. So, I’m both in the anesthesia space and then in the anesthesia-adjacent spaces. Dr. Sherrer and I are partners in the anesthesia space. We’re really excited to be here and talk with you all today.
Kevin Pho: Alright, so let’s talk about your KevinMD article, Care Teaming: A New Paradigm for Anesthesia Care Teams and Beyond. Matthew, tell us about the events that led Brooke and yourself to write this article, and maybe talk about the article itself for those who didn’t get a chance to read it.
Matthew Sherrer: Yeah, this is a real-life story for us. We have actually lived this and done it here at UAB. About five years ago, the relationship between our anesthesiologists and CRNAs was incredibly sour. It was broken. I would say we still refer to events back then as our “trust fracture.” We realized at that point that our communication and our relationship were so bad that we were likely a threat to patient safety.
Our institution, being as supportive as they are, recognized that and helped us make it better. They hired a skilled facilitator, a psychologist consultant, to work with our teams. We are now five years out from that point, and we have really, I think, helped change the culture back to one of collaboration and mutual respect through our ACT Talk Team.
Kevin Pho: What is the ACT Talk Team?
Matthew Sherrer: That’s the Anesthesia Care Team Optimization Committee. That’s what we call the group that got together. A lot of amazing people in that group did some really, really hard things at the beginning and are now on the back end doing some really cool things. But it took a lot of courage to sit and have some of those early discussions.
One of the things we talked about early on in those meetings was these ideas such as “care teaming,” with teaming being an Amy Edmondson concept, “collective intelligence” being an Anita Woolley concept, and “mutual learning” being a Roger Schwartz concept. All of these concepts have a few common threads, such as continuing the flow of information through conversation, right? Inviting information from all parties on the team, and then empathy—actually caring about your teammates. Getting to know them, spending time with them outside of work, knowing about their families, and knowing more about them so that you care about them, develop that relationship, and carry it over into your workspace.
A lot of work has gone into this. We chose to focus on Amy Edmondson, who’s a titan in the world of teaming, to talk about these concepts and to say that in our world, we have professional politics, and those things can spill over into our workspace.
I personally think that this often happens in health care, and rather than avoid it or just bury our heads in the sand, let’s actually discuss these things. Let’s discuss the undiscussable and see if we can use that to make us better.
Brooke Vining: Yeah, I think you nailed it. What you really hit on that I think was important in the preliminary part of our journey was the fact that we had become purely transactional. We weren’t relational; we weren’t having those kinds of connective touch points. We certainly weren’t doing it intentionally. If it happened organically among some of our teams, it kind of just happened, but we weren’t focusing on it, and we were not fracture-proof by any stretch of the imagination. I know personally for myself, I didn’t even realize how vulnerable we were until we had the trust fracture.
With the benefit of hindsight, we had been teetering on that point for many, many years. Then, you know, we did have a more frank trust fracture, but we were already there. We were right at the precipice, looking over that big canyon and prepared to fall, and all it took was one push. That’s what happened.
Kevin Pho: Brooke, during that time of tension and perhaps leading up to that trust fracture, what were some examples of the issues that contributed to that from your perspective?
Brooke Vining: Right. So, at the time, I wouldn’t have had the words for it, but it was microaggressions. It was kind of death by a thousand cuts throughout the workday. These were things we had become accustomed to tolerating, such as being terse, even if it was just a simple sentence in our preoperative area, or a lack of communication, such as an anesthesiologist walking in and saying, “Oh, I wanted this setup,” and the CRNA finding themselves on their heels saying, “Oh, I didn’t anticipate that.”
Now, I may look like I wasn’t ready to provide care for the patient. It was just this really disjointed flow throughout our day. I know now, with the benefit of hindsight, that those kinds of microaggressions have serious cumulative impacts over time. They’re not survivable long-term. I know that for certain. And I would say it predisposed us to the vulnerabilities that I just mentioned, where we could not take a single blow and have an organic, passive recovery. It required an intentional recovery with our facilitator, as Dr. Sherrer mentioned.
Kevin Pho: Matthew, you mentioned that these trust fractures eventually jeopardized patient care. How did that happen? What’s an example of that?
Matthew Sherrer: When I say our relationship was bad, I mean it was bad—so bad that people would see an anesthesiologist, me or others, coming down the hall, turn, and go the other way. I was not being called for induction, not being called for emergence—just that communication, which is so important to team-based anesthesia care, was lacking. We kind of go out and tell this story now as a cautionary tale. Please, anybody listening, don’t let your team become so fractured that you are a threat to patient safety. None of us come to work every day and say, “You know what? I’m going to be mediocre at patient care today.” We all come to work wanting to be excellent. Don’t let your teams get to this point. Take our story as a cautionary tale.
We think that we have definitely changed our culture to be more collaborative. I know that communication has improved. So, please read this article and feel free to contact us. We are happy to share our journey with anyone who will listen because it really does come down to our patients and us.
Kevin Pho: So, Brooke, tell us about that turning point that brought both sides together. What was that like? What led up to it? Was there a third party that brought you guys together?
Brooke Vining: Right. So, there was a sort of presentation to introduce anesthesiology assistants. Some of the listeners may be aware that these are practitioners who provide anesthesia care in a team-based model along with anesthesiologists. While that does exist in Alabama to some extent, there’s not a large platform or a large number of AAs practicing in our state, and certainly not any training programs at UAB.
We became aware, and by “we” I mean the UAB CRNAs, of a presentation that Dr. Sherrer participated in, which was asking the question, “Do we have an anesthesia provider shortage? If the answer is yes, what are all of our options here? What are the opportunities to increase our provider numbers to care for our patients?”
We went home one day, somewhat loosely knitted together—of course, fraught with the microaggressions I mentioned earlier—but we came back the next day as a team fully divided. We all became aware of the icy nature of our relationship, and that was escalated to our hospital leadership, to our vice president of clinical operations, and ultimately to our CEO of the health system. They took heed of our warning. We were self-reporting, saying, “Hey, we’ve got an issue here. This is not going well. This is worse than it’s ever been. I’m not sure how we pull ourselves back together.” There was no one willing to take the first step. And even when there was a first step, it was ill-received—like the olive branch might have been tried to pass across the line, but there was nobody standing there to take it.
At that time, we escalated it, and our VP and CEO really listened to us. When we looked at it through the lens of patient safety concerns, they listened and brought in a third party to come in, do mediation, and start the kinds of conversations we needed to get us back on the road toward teaming again.
Kevin Pho: Matthew, take us into that room where mediation happened. What was it like? What was the tenor of the conversation, and how did you all manage, despite that culture of tension? What was it like inside that room?
Matthew Sherrer: It was tense. I remember it well. It was divided. I distinctly recall our MD leadership team on one side and our CRNA leadership team on the other side of the table, very much divided physically. But what our facilitator did so beautifully was this approach of, “Hey, in this first session, Matt, as an anesthesiologist, you don’t get to say really anything other than what you hear your CRNA colleagues say.”
So, Brooke and her colleagues got to say, “Hey, you know what? This is what you guys have done that makes us feel unimportant, unnecessary, and devalued. This is how your actions have impacted us.” And I didn’t get to say, “No, no, no, no, that’s not what happened. That’s not what I mean.” All I got to say was, “Brooke, I’m hearing you say this.” That’s it.
We kind of walked away. There were some harsh things said in that meeting; it was painful. And we walked away from it, I think, probably not feeling that great. However, a few weeks later, we got to do the counter of that where the anesthesiologists got to express how they felt devalued by some of the CRNA narratives out there. The CRNAs didn’t get to say anything other than, “This is what we hear you say.”
With those things on the table, we were able to rebuild. Having that facilitator was incredibly important to keep us within certain guidelines. We used the Roger Schwartz model of mutual learning as a guide, and those were our guardrails. She kept us on that road and out of the ditch. From there, the conversations became much more fruitful. We began to see what other people brought to the table, what other perspectives and skills they had, and then eventually we realized, “Hey, if we do this right, we are greater than the sum of our parts.” But we found ourselves not even additive; we were inhibitory to one another. If we do this correctly, we can get to synergy—we can be greater than the sum of our parts—but that’s going to take work. And here we are, five years later. Can I say we’re 100% there? No, I’m not going to say that, but I can say we’re certainly much farther down that road than where we started.
Kevin Pho: Brooke, how long did it take before you noticed some appreciable change after those initial meetings?
Brooke Vining: Yeah, that’s a great question. I think about that sometimes when I’m reflecting on this journey. I think it was probably the third session. The two sessions that Matt just explained—there was a third session where we started to try to focus on what was more alike than different. We started to ask each other, “What brought you to anesthesia? Why do you do this for a living? What attracted you to the specialty?” As I started to hear the anesthesiologists say the same things that I would say when that question was posed to me, we started to see where we were more alike than different.
That really then started to make me challenge myself to say, “OK, I’ve almost chosen openly to not think that we have the same ideals or that we didn’t come to the table with the same goals or that we don’t want the same things out of our career.” I had decided with preconceived notions that they were different from the CRNAs, and the anesthesiologists had decided the same thing. That was really the turning point. I will say that it was probably more of an internal awareness that started to grow in us versus an external ability to share and say, “OK, this feels like common ground.” But that, for me, was when I really started to personally feel a shift.
Kevin Pho: And Matt, was there anyone on the MD or CRNA side that couldn’t bridge that gap? Were you unified on each side in terms of bridging this gap and making things better, or was it a bridge too far for some people?
Matthew Sherrer: Definitely, there were some people for whom it was a bridge too far. I would say both sides faced a lot of pressure. This was a very public thing here at our institution. People knew when those meetings happened, and you better believe I had people in my ear saying, “Hey, Matt, walk in there and tell them this.” I’m sure Brooke had people in her ear saying, “Hey, Brooke, walk in there and tell Matt this.” We had people kind of telling us, “This is what you should go tell them.” It was tough to bridge that gap. I think it took courage for the leaders who were in the room.
But we ultimately got to a place where we said, “You know what? We don’t actually decide that—the credentials committee decides that; our training decides that—who can do what.” What we want, and where I believe we’re getting to, is a team that, before they take care of a patient, can discuss the patient, discuss the care of the patient, discuss how they want to do things, and acknowledge the learners in the room. “Hey, SRNA, do you still need numbers and experience in this? Hey, medical resident, do you still need training on this?” Let’s get to a point where at the head of the bed around that patient, we can all respectfully discuss how we’re going to take care of that patient in the best way possible. Let’s get to a point where we can do that individually, not where a guiding committee comes out and says, “This is what we’re going to do.”
So yeah, we faced a lot of pressure at the beginning, but I think we’re at a much better place now than where we started.
Kevin Pho: Matthew, is a situation like this specific to your hospital area? What are you hearing from hospitals across the country? Is this pretty common nationwide?
Matthew Sherrer: Yeah, so I think scope of practice is a big deal in health care. I want to get this out there—I am a member of the American Society of Anesthesiologists. I support my specialty. I’m actually the president-elect of my state society. I love the specialty of anesthesiology. It has given me an amazing life, and therefore I owe this specialty my advocacy. Brooke is a fellow of the American Association of Nurse Anesthetists, right? That’s a tremendous honor. She has a wonderful career because of that specialty and should advocate for that specialty.
Politics still come into play. Can we get to a place where we have balance in our thinking, where we can acknowledge our specialty, but we can potentially say, “Hey, on the front lines, this is what we do. This is what we believe in. These are the values that we hold, which are an inclusive, respectful, and fulfilling workplace?” And let’s actually, on the front lines, do something different. Let’s come together in a collaborative nature.
So, we are certainly by no means saying politics are bad and we should avoid them. However, we are saying that on the front lines, we believe acknowledging that tension is necessary. When we do, we can build on that and build the best health care teams that we possibly can through those teaming values.
Brooke Vining: I think the relationship between the CRNAs and the MDs is much better today than it was in 2019. The progress has really been tremendous. But as Matt has mentioned a couple of times, we’re not finished. There’s still opportunity. I think the opportunities are not only internal but external—outside the walls of UAB.
This was all behavior and mindsets that we had to unlearn because we had not been taught proper teaming out of the gate. I was never taught that in nursing school or in nurse anesthesia school. Matt has shared that it wasn’t really taught in medical school or in his residency. So, we spent these last five years unlearning that behavior. Where we see the value-add that we can contribute now is in asking, “How do we not continue to educate providers to enter the health care environment and have to unlearn behavior?” What if we taught this on the front end? What if they don’t come in and create these fragilities among the teams that then impact patients? What would that look like?
That really is where I think our team is now—understanding the recovery that we’ve had, and it’s been successful, and it’s mighty, and we’re proud of it. But also, what do we do with our recovery? We don’t just hold on to it inside the walls of UAB or where we’re currently practicing. We don’t keep it to ourselves.
Kevin Pho: So I’m going to ask both of you the same question, and Brooke, I’m going to ask you first. From your perspective as a CRNA, what kind of lessons can you share with other CRNAs so a situation like this doesn’t happen? Because if left untreated or unresolved, like Matt said earlier, it could harm patient care. So, Brooke, what would be your advice to other CRNAs who may be listening to you here?
Brooke Vining: I think as a student registered nurse anesthetist (SRNA), when I was training and early in my career, I developed an amount of tolerance for the microaggressions I mentioned earlier. I felt like that was part of being a CRNA, that you developed that tolerance for friction with the anesthesiologist you were working with on any given day, and that was just part of doing the job. That’s just an expected piece of practicing anesthesia in a team model.
So, I would really challenge that now. That should not be a piece of anyone’s day, both inside and outside of anesthesia. The toll that that takes over time, again, is not survivable for any team, and we’re not serving our patients well. There’s no valor in biting your tongue repeatedly. Now, do we engage in constant conflict? No, but we really have to take ownership of the fact that functioning as a team is just as important as the way we take care of the patient’s blood pressure or heart rate. There’s a moral imperative to function at a very high level in health care delivery today because there is nothing happening in a silo, again, both inside and outside of anesthesiology.
So, that would really be my advice—to move away from that cultural acceptance of friction in your day and take it more head-on to say, “How can we have a day where neither of us leaves mentally exhausted because we’ve had this death by a thousand cuts throughout our workday?”
Kevin Pho: Matthew, I’m going to ask you that same question. For the anesthesiologists who may be listening to you and may be experiencing the same situation you guys did five years ago, what’s your advice to them?
Matthew Sherrer: The day that it hit home for me was a year or so in. We did a survey of our ACT Talk leaders—kind of anonymous, but we wrote some comments out. One of them said, “I no longer go home and take out my frustrations from work on my family.” That was a gut punch. Number one, I can’t believe that I ever contributed to that, but number two, this is something worth doing. We should keep on down this path. That was a great motivation to continue.
As we’ve said, I don’t think this is an anesthesia-exclusive problem. This is something pervasive across health care, in other specialties, and at other hospitals. The kind of mindset change I had was that if I claim to be an evidence-based physician, if we all claim to be evidence-based health care clinicians, then if we concede that we certainly practice in a team environment—which health care is these days; health care is a team sport—then we also have to understand the evidence behind teamwork and what that means. It doesn’t mean one person yelling commands at other people. There are certain situations where that works. But if you take that mindset into everything you do, I believe you can actually damage the care that you provide to the patient.
That was a big shift for me—understanding the evidence of teamwork. It’s not something I learned in medical school. It’s not something I learned in residency. I would argue that I was even taught an extreme version of that to the contrary. To go unlearn that has been hard and incredibly rewarding. It’s something that Brooke and I want to continue to share with anyone who will listen.
Kevin Pho: We’re talking to Matthew Sherrer and Brooke Vining. Matthew is an anesthesiologist, and Brooke is a nurse anesthetist. They wrote the KevinMD article, Care Teaming: A New Paradigm for Anesthesia Care Teams and Beyond. Now I’m going to ask each of you to share some take-home messages that you want to leave with the KevinMD audience. Brooke, why don’t you go first?
Brooke Vining: We reference an article from Kotter called Our Iceberg is Melting. When this happened to us, not only did I not realize that my own iceberg was melting, but I didn’t even realize that we were on an iceberg together. There really is an opportunity to take a step back as clinicians in all specialties and ask yourself, “What’s going on with my teaming currently, and what’s not working?” Again, it’s a moral imperative to embrace what’s not working in a way that commits to changing it for your patients.
Kevin Pho: And Matthew, we’ll end with you.
Matthew Sherrer: Well said. To anybody who’s considering, “Hey, look, we recognize in our teams what Matt and Brooke are talking about. We want to embark on this journey.” I will tell you, it’s hard. Our Iceberg is Melting is a great book, a great guide, a great path. We actually have that up on the screen in every meeting: “Where are we on these eight steps of Kotter?” But change is hard, and you’re going to face resistance.
I like to go back to Simon Sinek, who talks about the law of diffusion of innovation. Change is a human phenomenon. We’re going to have some early adopters, but you’re going to have a lot of people who are in the late majority or even laggards who are going to resist. That used to bother me. It used to bother me that people would resist a change effort that I was trying to implement, that we were trying to implement. You kind of have to get to the point where you say, “That is a social human phenomenon. It’s OK.” We’re going to focus on those early adopters, see if we can get that early majority, and see if the wave can then spread. But there’s going to be pushback, and that’s OK.
As Brooke said, we believe this is a moral imperative for our health care teams. So, focus on those early adopters. You don’t completely ignore your colleagues who are laggards, but you also, at the same time, don’t let them drag you down in your efforts.
Kevin Pho: Brooke and Matthew, thank you so much for sharing your story, perspective, and insight. And thanks again for coming on the show.
Brooke Vining: Thank you.
Matthew Sherrer: Thank you.
