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Working around hierarchy

Resident and medical assistant teaming

Brooks, Joanna Veazey; Sheridan, Bethany; Peters, Antoinette S.; Chien, Alyna T.; Singer, Sara J.

doi: 10.1097/HMR.0000000000000224
Features: PDF Only

Background In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise.

Purpose This article sought to understand how resident–medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms.

Methodology We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding.

Results An intervention that promoted teamwork prompted resident–MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy.

Conclusion Among resident–MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy.

Practice Implications Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.

Joanna Veazey Brooks, MBE, PhD, is Assistant Professor, Department of Health Policy and Management, University of Kansas School of Medicine, Kansas City. E-mail:

Bethany Sheridan, BA, is Doctoral Student, Harvard University, Cambridge, Massachusetts.

Antoinette S. Peters, PhD, is Corresponding Faculty, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts.

Alyna T. Chien MD, MS, is Assistant Professor, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital and Harvard Medical School, Massachusetts.

Sara J. Singer MBA, PhD, is Professor, Department of Medicine, Stanford University School of Medicine and Graduate School of Business, California.

This research was supported by a grant from the Harvard Medical School Center for Primary Care. This study was approved by the Institutional Review Board at the Harvard T. H. Chan School of Public Health. This work was presented at two previous conferences, the Organization Theory in Health Care conference (2016, Nashville, TN) and the Academy of Management Annual Meeting (2017, Atlanta, GA).

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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