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Collaboration and Teamwork in the Health Professions

Rethinking the Role of Conflict

Eichbaum, Quentin MD, PhD, MPH, MFA, MMHC

doi: 10.1097/ACM.0000000000002015
Perspectives
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Whereas the business professions have long recognized that conflict can be a source of learning and innovation, the health professions still tend to view conflict negatively as being disruptive, inefficient, and unprofessional. As a consequence, the health professions tend to avoid conflict or resolve it quickly. This neglect to appreciate conflict’s positive attributes appears to be driven in part by (1) individuals’ fears about being negatively perceived and the potential negative consequences in an organization of being implicated in conflict, (2) constrained views and approaches to professionalism and to evaluation and assessment, and (3) lingering autocracies and hierarchies of power that view conflict as a disruptive threat.

The author describes changing perspectives on collaboration and teamwork in the health professions, discusses how the health professions have neglected to appreciate the positive attributes of conflict, and presents three alternative approaches to more effectively integrating conflict into collaboration and teamwork in the health professions. These three approaches are (1) cultivating psychological safety on teams to make space for safe interpersonal risk taking, (2) viewing conflict as a source of expansive learning and innovation (via models such as activity theory), and (3) democratizing hierarchies of power through health humanities education ideally by advancing the health humanities to the core of the curriculum.

The author suggests that understanding conflict’s inevitability and its innovative potential, and integrating it into collaboration and teamwork, may have a reassuring and emancipating impact on individuals and teams. This may ultimately improve performance in health care organizations.

Q. Eichbaum is professor of pathology, microbiology, and immunology; professor of medical education and administration; and director, Vanderbilt Pathology Education Research Group; director, Vanderbilt Pathology Program in Global Health; and clinical fellowship director, Vanderbilt University Medical Center, Nashville, Tennessee.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Quentin Eichbaum, Vanderbilt University Medical Center, TVC4511C, 1301 Medical Center Dr., Nashville, TN 37232; e-mail: Quentin.eichbaum@vanderbilt.edu.

Academic collaboration, I’ve learned over the years, is something of an oxymoron. More often than not, what is described by that term is really non-collaborative, or worse, pseudo-collaborative work, driven by the long-standing rituals of institutional seniority and professional and financial incentives to build higher silos and thicker walls. 1

Collaboration and teamwork have become buzzwords in the health professions, yet they remain poorly understood terms. Students and trainees are exhorted to be collaborative and to be team players, and educators evaluate them for attaining these attributes, which are considered core competencies. But how are these attributes interpreted, contextualized, and evaluated? The health professions have tended to portray collaboration and teamwork mostly in positive terms like cooperation, synergy, harmony, and altruism, with scant attention given to their veiled features like competition and conflict. 2

In the health professions, conflict is often considered disruptive, inefficient, unprofessional, and a potential source of error that can impact patient safety. 3 Whereas business management has long appreciated the inevitability of conflict and realized its innovative potential in organizations, 4,5 the health professions have struggled to reconcile conflict with efficiency, ingrained views of professionalism, and concerns about safety, and thus tend to avoid conflict or resolve it quickly. Does conflict have a constructive role in the health professions, or should health professionals try to avoid it?

In this article, I will describe how perspectives on collaboration and teamwork have changed in recent decades as health care systems have grown in complexity. 6,7 I will discuss how the health professions have neglected to appreciate the positive attributes of conflict for reasons that include (1) individuals’ fears about being negatively perceived and the potential negative consequences in an organization of being implicated in conflict, (2) constrained views and approaches to professionalism and to evaluation and assessment, and (3) lingering autocracies and hierarchies of power that view conflict as a disruptive threat. I will then present three alternative approaches to more effectively integrating conflict into collaboration and teamwork in the health professions.

I will refrain from defining collaboration and teamwork (given the complexity of these topics) and instead use these terms in their broadest sense, while understanding that they are distinct terms (e.g., collaboration can occur between individuals independent of a team or teamwork). Likewise, I will use conflict in its broadest sense to encompass associated terms such as dissent, negativity, and contradiction, and I will avoid its multifarious cultural dimensions 8–10 by focusing mostly on the U.S. context. Finally, this is not an article about conflict management or resolution but, rather, a framework of perspectives for rethinking an integrative role for conflict in collaboration and teamwork in the health professions.

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Changing Perspectives of Collaboration and Teamwork

The concept of teams obscures, rather than reveals, the real relationship challenges our organizations face. Teams are a fiction, a verbal convenience, rather than a useful description of how people in a firm cooperate and collaborate to create value. 11

Health care systems have become increasingly more complex. 12–14 These changes have impacted the health care work environment and how health professionals collaborate and work in teams. At the same time, perspectives on collaboration and teamwork have been changing. For example, the very notion that teams are more effective and always outperform individuals has been cogently challenged by Hackman 5 and others 15,16 :

Many people act as if being a team player is the ultimate measure of one’s worth, which it clearly is not. There are many things individuals can do better on their own, and they should not be penalized for it. 5

Engeström, 7 a Finnish sociologist, argued that teams are no longer stable entities but have become akin to knots that are “formed, dissolved … and reformed.” Some have suggested that viewing teams as knots allows for a fluidity that may be conducive to collaboration, 17 but others insist that “clear boundaries and demarcations” between teams is essential for effective collaboration. 18

Some evidence suggests that unstable teams, in which members have not had time to get to adjust to one another, are more prone to error and accidents. For example, a study of cardiac surgeons who operated at hospitals that were not their home base with teams that they had not previously worked with had higher patient mortality rates than those who operated at their home base with familiar teams. 19,20 Were these newly formed, error-prone teams also more conflict ridden? Or was some other factor responsible for their higher error rate?

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Rethinking the Role of Conflict in Teamwork and Collaboration

One fallacy about teams is that, to be successful, everyone must be friends. The research says it’s the other way round: team performance drives the quality of relationships. When teams are failing, this poor performance upsets their members—and they take their frustration out on one another. 21

Most studies of conflict in the health professions purport to demonstrate that it reduces a team’s performance by, for instance, causing dissatisfaction, distracting members, and inhibiting open discussion. 22,23 When conflict arises, health professionals tend to address it as a symptom to be treated and eradicated rather than trying to understand its root causes and eliciting its innovative potential.

Several studies show that making space for conflict and dissent on teams can promote the relay of important information and improve group decision making and performance. 24,25 Such studies suggest that embracing rather than avoiding conflict pays off and that organizations should create appropriate environments and develop strategies for integrating conflict. Studies of high-performing teams, such as world-class orchestras, have shown that rivalry and competition may render members more demanding of themselves and their team members, keeping the team’s purpose (rather than the individual’s own interests) in sharp focus. 26,27

In contrast to the health professions, the business professions have long recognized that conflict is not only unavoidable but can also be a source of learning and innovation. 24 Several terms have been coined in business to convey the positive side of conflict, including constructive controversy, 28 creative abrasion, 29 defensive pessimism, 30,31 and the obligation to dissent. 32

According to Lencioni, trust is a crucial quality for teams to develop to engage in constructive dissent and embrace conflict:

… teams that trust one another are not afraid to engage in passionate dialogue around issues and decisions that are key to the organization’s success. They do not hesitate to disagree with, challenge, and question one another, all in the spirit of finding the best answers, discovering the truth, and making great decisions. 33

Teams with a trust deficit may strive to avoid conflict, but such conflict avoidance can aggravate the distrust and may lead to an artificial harmony that diminishes team performance. 31,33 Bronson and Merryman 21 warn about the hazards of avoiding conflict for the sake of maintaining harmony:

Constant harmony may even be cause [for] alarm. A conflict-free team means that no one is bringing anything to the table that might engender controversy. The team members aren’t focused on the team’s purpose; instead they are focused on protecting the group’s relationships.

The health professions need to take a more integrative view of conflict to realize its constructive potential.

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Forced Collaboration Versus Think Different

How then might health professionals begin to reconceptualize conflict in a more integrative way? Leavitt and McKeown 34 discuss the concept of collaborative intelligence (CI), distinguishing this concept from notions of harmony, being nice, and being cooperative:

CI is more than being friendly or having a cooperative attitude. While there is nothing wrong with these traits, we’ve also worked with irascible, dogmatic, sarcastic people who had high levels of CI.

Iconoclast Steve Jobs of Apple Inc. quintessentially evinced such “negative” character traits, yet he had a high CI. Despite his temperamental leadership style, he developed a highly collaborative culture at Apple that allowed employees to “dignify the differences” 35 in how they worked together and thought about approaching challenges, epitomized in Jobs’s aphorism “Think different.” 36

Recent studies indicate that creative and innovative individuals are often nonconformists and this may put them at odds with their teams. 31 Owens 37 illustrates this point with his useful distinction between adaptive innovators, who work within the conforming parameters of team dynamics, and radical innovators, who challenge the team or organization by thinking differently. Radical innovators may “threaten group cohesion and cooperation,” and yet they enhance the group’s performance and drive its success. 37

Other studies have shown that teams that strive to resolve conflict by forcing consensus have an unrealistic view about the ease of attaining consensus and are prone to the most interpersonal conflict. 4 Members of a team have a need to have their participation recognized and their opinions heard and appropriately considered; forcing collaboration and consensus may ignore this need and, by extension, process fairness (or procedural justice). 38 Collaboration that is forced in this manner may be gauged by artificial measures, such as members being friendly or nice, 4,34 and can engender artificial harmony 33 or cordial hypocrisy 39 among collaborators.

The health professions are far from embracing a culture of dissent. Embracing conflict and contradictions presents a challenge to traditional authoritarian hierarchies. Leveling such hierarchies and democratizing the health professions may allow space for creative disruption and innovation. 40–42

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Power Hierarchies and the Constraints of Professionalism, and Evaluation and Assessment

Constraints of professionalism

Bleakley 43 suggests that the “structural legacy of autocracy and autonomy” in the health professions has resulted in constrained conceptions of professionalism resistant to democratic participation in the profession. Students and trainees are tacitly acculturated into these hierarchies under the guise of professionalism, and these hierarchies persist because they come “disguised as meritocracies.” 43

Collaboration and teamwork are often regarded as core competencies 44,45 in professional development that trainees must attain to be considered professional. But tools for evaluating and assessing these attributes remain inadequate. 46 While Ginsburg et al 47 argue that “Conflict has … long been identified as a critical component of professional development,” professionalism has generally taken a negative view of conflict. For instance, “unprofessional” behaviors associated with conflict are often adjudged without realizing how inextricably they are linked to the “exigencies of contexts.” 46

Lucey and Souba 48 suggest that current views of professionalism may be constrained by a preference for simplistic, technical solutions to unprofessional behavior and conflict that “solve” the problem quickly, rather than shared, adaptive solutions that take contexts and perspectives into account. Technical solutions are easier to devise and execute, whereas adaptive solutions demand a more considered approach to conflict. Adaptive solutions attempt to reintegrate unprofessional individuals into the health system and therefore take time and effort. Such solutions, however, are more consistent with collaboration:

Tackling the problem of professionalism as a complex adaptive challenge begins with developing a shared vision (the desired future state) and a shared understanding of the problem (the current reality). 48

Such a shared vision of collaboration more readily embraces conflict, contradiction, and dissent, allowing space for the conflicting viewpoints of seemingly uncollaborative individuals. Thus Collins’s 49 well-known adage about teamwork, “Get the right people on the bus and the wrong people off the bus,” can be a simplistic, technical solution rather than a shared, adaptive vision. It may allow little space for individual adaptation and is often too readily invoked as an excuse for firing or demoting nonconforming individuals who are perceived to be uncollaborative or poor team players. Adaptive solutions aim to integrate diverse individuals and viewpoints into teams and organizations and to understand the importance of contexts, which may place different demands on individuals and thus elicit different collaborative skills sets. 50

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Constraints of evaluation and assessment

Teams and individuals in organizations are constantly evaluated and assessed (both formally and informally), and this can make them feel insecure and unsafe. 51 The threat of evaluation and assessment can affect how teams and individuals approach and avoid conflict. As high achievers, health professionals and students nurture their professional image and reputation and generally fear being perceived, especially by those in power, as negative or fomenting conflict. 52 For example, a trainee requiring an evaluative letter of reference would be careful not to be perceived as argumentative with his referee, and a physician being considered for departmental promotion would try to avoid arguments with the department chair.

Moving toward less hierarchical and “safer” models of evaluation and assessment may allow for better integration of conflict into collaboration and teamwork. 53,54 Mann et al 54 stress “the importance of making it safe to ask for feedback and of providing careful … (and) credible feedback … based on … relationships of mutual respect.” However, studies suggest that such safety is still lacking in evaluation and assessment and in feedback models. 52

Constrained views of professionalism and of evaluation and assessment, in the setting of hierarchies of power in the health professions, 55 have impeded effective integration of conflict into collaboration and teamwork. In the sections that follow, I discuss three approaches to more effectively integrating conflict into models of teamwork and collaboration.

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Three Approaches to Integrating Conflict Into Collaboration and Teamwork in the Health Professions

Making interpersonal risk-taking safe (psychological safety)

One approach to integrating conflict and mitigating the adverse effects of the constrained views detailed above is through the development and nurturance of psychological safety (PS). PS was originally defined by Edmondson 51 as “a shared belief held by members of a team that the team is safe for interpersonal risk-taking.” The level of PS in an organization is “the degree to which people perceive their work environment as conducive to taking (these) interpersonal risks.” 51 Edmondson initially developed this concept in the late 1990s in the context of business management. Recently, the concept has resurfaced as the unanticipated finding of an intensive five-year study by Google Inc. that aimed to discover the attributes of the perfect team. Google’s search for the perfect team’s attributes had initially proved elusive until the study revealed that the single most important attribute of high-performing teams was PS. 56

Although PS has “much in common” with trust, Edmondson 52 is careful to distinguish the terms. For instance, PS is focused on more immediate consequences (e.g., it being safe to speak up in a meeting), whereas trust operates over a longer time frame; further, PS is focused on how safe and accepted one feels in a group, whereas trust is focused on how one feels about others.

Edmondson also distinguishes team PS from group cohesiveness, 52,57 and insists that PS “does not imply a cozy environment in which people are necessarily close friends, nor does it suggest absence of pressure or problems.” Whereas cohesiveness can interfere with the willingness to disagree and challenge others’ views because of closer affiliations or connections, PS does not compromise individual accountability. Excellence and achievement are rewarded without sanctioning poor performance, while acknowledging that “imperfection and error … are inevitable under conditions of uncertainty and change.” 52

By making it safe for team members to take interpersonal risks, PS allows them to approach conflict without fear of being negatively judged by the group or perceived as being disruptive. Among the benefits of fostering PS in health professional organizations is that it improves patient safety by reducing medical error:

… reluctance to take interpersonal risks can create physical risks in high-risk industries … where admitting mistakes and asking for help may be essential for avoiding catastrophe … particularly … in organizations where lives are at stake, such as in hospitals. 52

In a controlled study of medication errors in hospitals, PS was found to improve team members’ level of comfort in reporting errors, which ultimately led to a reduction in errors. 58 In surgical operating rooms, teams evincing PS allowed nonsurgeons to more readily voice their opinions within the health system power hierarchies, which led to reduced error rates. 59 Speaking out could be seen as introducing conflict into teams, but this was contained and mitigated by the presence of PS. 60 A lack of PS can impede the collective and iterative learning process that is essential for ensuring patient safety. 60,61 Edmondson et al 59,62 showed that cardiac surgery teams with PS were more likely to implement innovative technologies, such as minimally invasive cardiac surgery, which improved patient safety.

According to Edmondson, 52 “The best tactic for establishing psychological safety is demonstration by a team leader.” Team leaders can affect PS and team learning by enabling team members to take interpersonal learning and communication risks and by embracing error in a productive, nonpunitive manner. In doing so, leaders manage conflict in their teams. Moreover, leaders can manage power “in both directions … by empowering those in lower-status positions to speak up and … by minimizing the domineering tendencies of high-power individuals.” 52 PS thus allows for interpersonal risk-taking that mitigates conflict on teams and helps integrate it (and its innovative potential) into teams.

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Viewing conflict as a source of learning and innovation (activity theory and expansive learning)

A second approach to integrating conflict in collaboration and teamwork in the health professions comes from activity theory (AT), which offers a workplace theory that views conflict (or “contradiction”) not as a problem to be resolved but as a resource for learning and innovation. 7,63 Engeström 7 uses the term “contradiction” to describe the various conflicts and tensions in the workplace that generate disturbances, which may lead to positive change.

A version of AT known as cultural-historical activity theory considers, as its basic unit of analysis (or activity system), the social contexts of work. An activity system at work entails a “community of multiple points of view, traditions and interests” 64 that may become a source of contradiction. AT views these contradictions as positive learning opportunities that can lead to transformative change. When such change leads to something entirely new, the process is called learning by expanding or expansive learning. 64 While conflict does not always lead to expansive learning, it does cause an axial shift that can open up innovative opportunities. Individuals and teams should, therefore, not shy away from conflict but, rather, view it as a source of creative innovation.

One area in health care that can be a source of both conflict and expansive learning is medical error. While making mistakes can generate conflict, paradoxically it can also be a source of learning and transformative change. 65 For example, with morbidity and mortality rounds, the learning environment is designed to transform medical errors from finger-pointing sources of conflict into transformative learning experiences designed to reduce errors, improve care, and potentially introduce innovations.

A hindrance toward achieving such transformative learning experiences, Engeström 7 argues, is that health care teams and their operating contexts have “traditionally been very centralized and dominated by strong autocratic leaders, by physicians, and increasingly by professional business managers.” I turn now to a discussion of an approach for dealing with such impeding autocracies of power in the health professions.

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Democratizing hierarchies of power (health humanities)

The health humanities offer a third approach to integrating conflict into collaboration and teamwork in the health professions by enabling the democratization of power hierarchies. 40,66 Bleakley 40 and colleagues 67 have argued that the culture of medicine remains historically conditioned with authoritarian and hierarchical power structures. They ascribe such lingering autocracies of power to medicine’s paternalistic learning structures (in which knowledge is transmitted from “knowing” teachers to “deficient” trainees), positivist distrust of uncertainty and ambiguity, and historical “oppressive post-colonial contexts.” 67 Conflict poses a threat to hierarchies of power. Autocracies, therefore, tend to avoid or rapidly resolve conflict rather than embrace it. Lingard et al 68 and Whitehead 69 have likewise grappled with trying to democratize the health professions, given the professions’ “well-ingrained incentives for keeping structural hierarchies in place.” 68

Bleakley 40 and others 66,70 believe the health humanities have an essential role to play in “democratizing medical culture.” 40 The humanities, they insist, are better placed than the science, technology, engineering, and medicine disciplines to provide the imaginative conditions that underlie democratic values, such as tolerance, empathy, and critical consciousness. 71 These conditions and values are antithetical to autocracies of power.

Contrary to the notion that power hierarchies sustain an essential chain of command to avert medical errors and ensure patient safety, evidence indicates that rigid hierarchies may actually increase errors and jeopardize safety by impeding communication and the flow of information. 72 It has been repeatedly shown in the airline industry, where hierarchies have been associated with an increased risk of plane crashes, that hierarchies can jeopardize the efficacy of teams. 73

Bleakley 12,40 insists that power hierarchies in the health professions present unnecessary impediments that should be leveled. The humanities, he suggests, may serve a crucial role in leveling these hierarchies and democratizing the health professions as they educate toward the “creation … (and) … tolerance of ambiguity and uncertainty.” 40 Intolerance of ambiguity is the hallmark of authoritarian resistance of democracy; the humanities serve to counter such authoritarianism through open debate and tolerance of ambiguity and differences 40,74 :

The humanities diagnose social ills, such as unproductive authoritarian behavior grounded in intolerance of ambiguity, and suggest cures, such as tolerance of difference, through open debate and collaborative activities. 40

Nussbaum 66 concurs that the humanities are the discipline most suited for promoting democracy as they draw attention to social problems, question authority, and favor diversity and tolerance of differences.

To more effectively integrate conflict as a source of innovation in collaboration and teamwork, and as an emancipation from the adverse effects of power hierarchies, humanities programs should not be relegated to the periphery of the health professions curriculum (nor treated just “as compensation for an overdose of science” 63 ). They should, instead, occupy a central position in the health professional curriculum. (The Plymouth University School of Medicine and Dentistry in the United Kingdom introduced the humanities as a core part of an integrated curriculum in 2001–2002, and appears to be the only medical school where the humanities occupy such a core position in the curriculum. 40 ) Such a central curricular position does not insinuate intellectual predominance but, rather, positions the humanities as intellectually accessible to the other disciplines and as an interdisciplinary resource for analyzing complex topics and for conceptual revitalization. 63 Designed to deal with complexity, uncertainty, and ambiguity, the humanities are better equipped than are the science, technology, engineering, and medicine disciplines for substantive conceptual analysis and for challenging autocracies of power.

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Conclusions: Rethinking Collaboration and Teamwork

The health professions have been slow to integrate conflict into their models of collaboration and teamwork. Among the reasons for such conflict aversion are (1) individuals’ fears about being negatively perceived and the potential negative consequences in an organization of being implicated in conflict, (2) constrained views and approaches to professionalism and to evaluation and assessment, and (3) lingering autocracies and hierarchies of power that view conflict as a disruptive threat. Given the complexity and rapidity of change in health care and the associated turmoil entailed, the health professions need to consider how to more effectively integrate conflict into collaboration and teamwork.

In this article, I have proposed three approaches to integrating conflict into teamwork and collaboration in the health professions: (1) cultivating PS on teams to make space for interpersonal risk-taking without undue fear of the negative consequences of conflict; (2) viewing conflict as a source of expansive learning and innovation (through models such as AT); and (3) democratizing hierar chies of power through education in the humanities, which provide the imaginative conditions for the tolerance of ambiguity and uncertainty, and ideally by advancing the humanities to the core of the curriculum.

Collaboration and teamwork remain poorly understood attributes (or sociopolitical constructs 75 ) for which educators have scant measurement tools and which, therefore, remain freighted with assumptions and myths. (In Table 1, I present 10 such myths with their associated reality checks.) Whether conflict enhances or impedes these attributes may depend on complex intersections of individual and contextual factors. Conflict is nonetheless inevitable, and the health professions should learn to embrace and harness its educational and innovative potential.

Table 1

Table 1

Finally, conflicts are often relatively minor disagreements that get exaggerated. Freud 76 suggested, “It is precisely the minor differences in people who are otherwise alike that form the basis of feelings of strangeness and hostility between them.” Blok 77 referred to this as the narcissism of small differences, while White and Langer 78 have called it horizontal hostility. Understanding that many conflicts arise from such relatively insignificant differences is reassuring and emancipating as it softens the perceived threat of conflict. Moreover, it opens a path toward embracing and integrating conflict into collaboration and teamwork in the health professions.

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References

1. Abele J. Bringing minds together. Harv Bus Rev. 2010;89:86–93, 164.
2. Flin R, Fletcher G, McGeorge P, Sutherland A, Patey R. Anaesthetists’ attitudes to teamwork and safety. Anaesthesia. 2003;58:233–242.
3. Clancy CM, Tornberg DN. TeamSTEPPS: Assuring optimal teamwork in clinical settings. Am J Med Qual. 2007;22:214–217.
4. Eisenhardt KM, Kahwajy JL, Bourgeois LJ 3rd.. How management teams can have a good fight. Harv Bus Rev. 1997;75:77–85.
5. Hackman JR. Leading Teams: Setting the Stage for Great Performances. 2002.Boston, MA: Harvard Business School Press
6. Paradis E, Pipher M, Cartmill C, Rangel JC, Whitehead CR. Articulating the ideal: 50 years of interprofessional collaboration in medical education. Med Educ. 2017;51:861–872.
7. Engeström Y. From Teams to Knots: Activity-Theoretical Studies of Collaboration and Learning at Work. 2008.Cambridge, UK: Cambridge University Press
8. Hofstede GH, Hofstede GJ, Minkow M. Cultures and Organizations: Software of the Mind: Intercultural Cooperation and Its Importance for Survival. 2010.3rd ed. New York, NY: McGraw-Hill Co
9. Meyer E. The Culture Map: Breaking Through the Invisible Boundaries of Global Business. 2014.New York, NY: PublicAffairs
10. Senge PM. The Fifth Discipline: The Art and Practice of the Learning Organization. 2006.New York, NY: Crown Business
11. Michael S. No More Teams: Mastering the Dynamics of Creative Collaboration. 1995.New York, NY: Doubleday
12. Bleakley A. Blunting Occam’s razor: Aligning medical education with studies of complexity. J Eval Clin Pract. 2010;16:849–855.
13. Rouse WB. Health care as a complex adaptive system: Implications for design and management. Bridge (Wash D C). 2008;38:17–25.
14. Mennin S. Complexity and health professions education. J Eval Clin Pract. 2010;16:835–837.
15. Cain S. Quiet: The Power of Introverts in a World That Can’t Stop Talking. 2012.New York, NY: Crown Publishing
16. Coutu D, Beschloss M. Why teams don’t work. Harv Bus Rev. 2009;87:98–105.
17. Lingard L, McDougall A, Levstik M, Chandok N, Spafford MM, Schryer C. Representing complexity well: A story about teamwork, with implications for how we teach collaboration. Med Educ. 2012;46:869–877.
18. Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E, Deutschlander S. Role understanding and effective communication as core competencies for collaborative practice. J Interprof Care. 2009;23:41–51.
19. Huckman RS, Pisano GP. The firm specificity of individual performance: Evidence from cardiac surgery. Manage Sci. 2006;52:473–488.
20. Colvin G. Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will. 2015.New York, NY: Portfolio/Penguin
21. Bronson P, Merryman A. Top Dog: The Science of Winning and Losing. 2013.New York, NY: Random House
22. De Dreu CK. The virtue and vice of workplace conflict: Food for (pessimistic) thought. J Organ Behav. 2008;29:5–18.
23. De Dreu CK. When too little or too much hurts: Evidence for a curvilinear relationship between task conflict and innovation in teams. J Manage. 2006;32:83–107.
24. Van de Vliert E, De Dreu CK. Optimizing performance by stimulating conflict. Int J Confl Manag. 1994;5:211–222.
25. Pondy LR. Reflections on organizational conflict. J Organ Behav. 1992;13:257–261.
26. Hackman JR. Learning more by crossing levels: Evidence from airplanes, hospitals, and orchestras. J Organ Behav. 2003;24:905–922.
27. Weiss J, Hughes J. Want collaboration. Harv Bus Rev. 2005;83:93–101.
28. Tjosvold D, Tjosvold MM. Guzzo RA, Salas E. Cooperation theory, constructive controversy, and effectiveness: Learning from crises. In: Team Effectiveness and Decision Making in Organizations. 1995:San Francisco, CA: Jossey-Bass; 79–112.
29. Barton DL. Wellsprings of Knowledge. 1995.Boston, MA: Harvard Business School Press
30. Norem JK, Cantor N. Defensive pessimism: Harnessing anxiety as motivation. J Pers Soc Psychol. 1986;51:1208–1217.
31. Grant AM. Originals: How Non-Conformists Move the World. 2016.New York, NY: Viking
32. Eden J, Long T. The obligation to dissent. Great Leadership Blog. http://www.greatleadershipbydan.com/2014/04/the-obligation-to-dissent.html. Published April 10, 2014. Accessed September 12, 2017.
33. Lencioni P. The Five Dysfunctions of a Team: A Leadership Fable. 2002.San Francisco, CA: Jossey-Bass
34. Leavitt M, McKeown R. Finding Allies, Building Alliances: 8 Elements That Bring—and Keep—People Together. 2013.New York, NY: John Wiley & Sons
35. Markova D, McArthur A. Collaborative Intelligence: Thinking With People Who Think Differently. 2015.New York, NY: Spiegel & Grau
36. Isaacson W. The real leadership lessons of Steve Jobs. Harv Bus Rev. 2012;90:92–102.
37. Owens DA. Creative People Must Be Stopped: Six Ways We Kill Innovation (Without Even Trying). 2011.San Francisco, CA: John Wiley & Sons
38. Thibaut JW, Walker L. Procedural Justice: A Psychological Analysis. 1975.Hillsdale, NJ: L. Erlbaum Associates
39. Fineberg HV; Institute of Medicine. Deadly Sins and Living Virtues of Public Health. 2012.Washington, DC: Institute of Medicine of the National Academies
40. Bleakley A. Medical Humanities and Medical Education: How the Medical Humanities Can Shape Better Doctors. 2015.New York, NY: Routledge
41. Kumagai AK, Jackson B, Razack S. Cutting close to the bone: Student trauma, free speech, and institutional responsibility in medical education. Acad Med. 2017;92:318–323.
42. Bleakley A. The perils and rewards of critical consciousness raising in medical education. Acad Med. 2017;92:289–291.
43. Bleakley A. Jones T, Wear D, Friedman L. The medical humanities in medical education: Toward a medical aesthetics of resistance. In: Health Humanities Reader. 2014.New Brunswick, NJ: Rutgers University Press
44. Eichbaum Q. Acquired and participatory competencies in health professions education: Definition and assessment in global health. Acad Med. 2017;92:468–474.
45. Lingard L. Hodges BD, Lingard L. Rethinking competence in the context of teamwork. In: The Question of Competence: Reconsidering Medical Education in the Twenty-First Century. 2012.Ithaca, NY: ILR Press
46. Hodges BD, Ginsburg S, Cruess R, et al. Assessment of professionalism: Recommendations from the Ottawa 2010 Conference. Med Teach. 2011;33:354–363.
47. Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: A new conceptual framework for evaluating professionalism. Acad Med. 2000;75(10 suppl):S6–S11.
48. Lucey C, Souba W. Perspective: The problem with the problem of professionalism. Acad Med. 2010;85:1018–1024.
49. Collins J. Good to Great: Why Some Companies Make the Leap… and Others Don’t. 2001.London, UK: Random House
50. Keltner D. The Power Paradox: How We Gain and Lose Influence. 2016.New York, NY: Penguin Books
51. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44:350–383.
52. Edmondson AC. Managing the Risk of Learning: Psychological Safety in Work Teams. 2002.Boston, MA: Harvard Business School Press
53. Eva KW, Regehr G. “I’ll never play professional football” and other fallacies of self-assessment. J Contin Educ Health Prof. 2008;28:14–19.
54. Mann K, van der Vleuten C, Eva K, et al. Tensions in informed self-assessment: How the desire for feedback and reticence to collect and use it can conflict. Acad Med. 2011;86:1120–1127.
55. Hafferty FW, Tilburt JC. Fear, regulations, and the fragile exoskeleton of medical professionalism. J Grad Med Educ. 2015;7:344–348.
56. Duhigg C. What Google learned from its quest to build the perfect team. N Y Times Mag. February 25, 2016. https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html?mcubz=1. Accessed September 12, 2017.
57. Janis IL. Groupthink: Psychological Studies of Policy Decisions and Fiascoes. 1982.Boston, MA: Houghton Mifflin
58. Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units. Crit Care Med. 1997;25:1289–1297.
59. Edmondson AC, Bohmer R, Pisano GP. Mannix B, Neale M, Grifith T. Learning new technical and interpersonal routines in operating room teams: The case of minimally invasive cardiac surgery. In: Research on Managing Groups and Teams: Technology. 2000:Vol 3. Stamford, CT: JAI Press; 29–51.
60. Schon DA. The Reflective Practitioner: How Professionals Think in Action. 1991.New York, NY: Basic Books
61. West MA, Anderson NR. Innovation in top management teams. J Appl Psychol. 1996;81:680–693.
62. Edmondson A, Bohmer R, Pisano G. Disrupted routines: Team learning and new technology implementations in hospitals. Adm Sci Q. 2001;46:685–716.
63. Bleakley A. Broadening conceptions of learning in medical education: The message from teamworking. Med Educ. 2006;40:150–157.
64. Engeström Y. Expansive learning at work: Toward an activity theoretical reconceptualization. J Educ Work. 2001;14:133–156.
65. Schultz K. Being Wrong: Adventures in the Margin of Error. 2010.London, UK: Ecco
66. Nussbaum MC. Not for Profit: Why Democracy Needs the Humanities. 2010.Princeton, NJ: Princeton University Press
67. Bleakley A, Bligh J, Browne J. Medical Education for the Future: Identity, Power and Location. 2011.Dordrecht, Netherlands: Springer
68. Lingard L, Vanstone M, Durrant M, et al. Conflicting messages: Examining the dynamics of leadership on interprofessional teams. Acad Med. 2012;87:1762–1767.
69. Whitehead C. The doctor dilemma in interprofessional education and care: How and why will physicians collaborate? Med Educ. 2007;41:1010–1016.
70. Macneill PU. The arts and medicine: A challenging relationship. Med Humanit. 2011;37:85–90.
71. Kumagai AK, Lypson ML. Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Acad Med. 2009;84:782–787.
72. Xyrichis A, Ream E. Teamwork: A concept analysis. J Adv Nurs. 2008;61:232–241.
73. Gladwell M. Gladwell M. The ethnic theory of plane crashes. In: Outliers: The Story of Success. 2008:New York, NY: Little, Brown and Company; 177–223.
74. Bleakley A. Seven types of ambiguity in evaluating the impact of humanities provision in undergraduate medicine curricula. J Med Humanit. 2015;36:337–357.
75. Lurie SJ, Mooney CJ, Lyness JM. Measurement of the general competencies of the Accreditation Council for Graduate Medical Education: A systematic review. Acad Med. 2009;84:301–309.
76. Freud S. Strachey J. Richards A. The taboo of virginity [1917]. In: The Penguin Freud Library. On Sexuality. 1991:Vol. 7. Harmondsworth, UK: Penguin Books; 261–283.
77. Blok A. The narcissism of minor differences. Eur J Soc Theory. 1998;1:33–56.
78. White JB, Langer EJ. Horizontal hostility: Relations between similar minority groups. J Soc Issues. 1999;55:537–559.
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