Teaching teamwork is increasingly relevant in medical education as many factors threaten the ability of trainees to coordinate their individual efforts to care for patients. Contemporary medical training places coworkers together for variable—often short periods of time. Each month, teams form and then disband, posing a challenge to team cohesion.41
Additionally, work-hour restrictions necessitate increasing emphasis on the coordination of roles, facilitation of transfers, and supervision. In their examination of medical claims between 1984 and 2004, Singh et al. reported that teamwork breakdowns stemming from communication breakdowns and handoff errors were a contributing factor in 70% of the cases.42
The authors suggested that the potential for medical errors would only increase with changes in work-hour regulations. Teaching trainees to work together effectively may play an important role in minimizing these risks.
All of the teamwork curricula reviewed used reasonable educational strategies, such as engaging subjects in active learning and the use of referenced teamwork models.28,29,31,34,37
Most used reflection or structured feedback on performance and appropriate educational strategies for skills training particularly within the context of relatively stable medical teams such as code teams. Few curricula, however, involved learners in experiences for greater than 8 weeks. Teamwork training may require longitudinal instruction to address common team-related problems in medicine. For example, coordinating patient handoffs by asynchronous individuals or participating in long-term projects such as continuous quality improvement (CQI) may benefit from teaching teamwork principles over time. Additionally, longitudinal curricula would also allow teamwork curricula to be combined with teaching of other skills (CQI) and allow trainees to apply their learning in a variety of medical contexts.43
For teamwork skills to be incorporated into ongoing behavior they may need to be reinforced in real-life environments, in the informal or hidden curricula of training institutions.44,45
In this article, we have used the framework described by Baker, which we feel is comprehensive, can provide guidance for curricular design, and lends itself to hypothesis testing. Incorporating a greater number of Baker’s principles was associated with larger overall median effect sizes, yet we note that 3 of these principles were present in 4 or fewer articles: backup behavior, mutual performance monitoring, and being on the same page. It is possible that incorporating these principles into a more comprehensive teamwork model will help those engaged in curriculum development to design more effective programs.
Another possibility is that the association of positive outcomes and comprehensive use of Baker’s principles may simply be the result of increasing the likelihood that the right teamwork principles were taught for a given context. Different teamwork principles may be more or less important depending on the context. For example, teaching teamwork may address handoffs more effectively if curriculum developers emphasize specific teamwork principles, such as mutual performance monitoring, shared mental models, and backup behavior, over principles such as leadership.
Although several curricula in this review used validated instruments28,31–33,35,37,39
to assess teamwork, evaluation methodologies were generally weak. No evaluations used randomization and few used a controlled design. Only one looked at a clinical outcome: patient satisfaction. Self-assessments of knowledge, perceived skill attainment, and a lack of long-term follow-up of learner outcomes further limit the conclusions that can be drawn from these evaluations.46
Developing metrics that are specific to teamwork principles would allow investigators to characterize the relative importance of each teamwork principle and the degree to which a principle is present.
The strengths of this systematic review include a methodical literature search of several databases with the assistance of a medical librarian, the use of 2 independent reviewers to extract data, and the use of a teamwork training assessment tool derived from a published theoretical framework to synthesize our data. Certain methodological limitations, however, should be considered in interpreting the results. First, there may be publication bias in reviews that include only published articles. We did create a funnel plot of effect size versus sample size, which demonstrated approximately equal distribution of studies with low and high effect sizes at different sample sizes, providing some evidence against a significant publication bias. Second, our search strategy was limited to English-only articles. Third, we used median effect sizes to compare results across studies using different outcome measures, which have the disadvantage of giving equal weight to both strong and weak evaluations. However, these methods have been recommended by others24–26
as a way to synthesize heterogeneous outcomes common in studies of medical curricula. Fourth, we could not address the potential correlation between teamwork principles because of the small sample size. Fifth, our assessment of Baker’s principles only counts presence or absence and not the quality of content, which was frequently not described. Finally, because of the small number of studies in our review, a few outlier studies may have excessively influenced the correlation between the number of teamwork principles used and the effect size of the results. To account for this, we conducted a sensitivity analysis that eliminated the highest and lowest data points and showed a similar but nonsignificant trend (p
Notwithstanding these limitations, this review demonstrates that reported curricula employ sound educational principles, appear to be modestly effective in the short term, and seem to be more effective when they address more teamwork principles. Future curricular work and evaluation should focus on context-specific teamwork training, the relation between specific curricular content/educational methods and outcomes, and improved evaluation strategies, including randomized trials, long-term follow-up, and stronger outcome measures.