S6 Ep4 Swarms, X-Teams, and Routine vs. Critical Communication (Recast)
This week’s Recast is from April 2020.
Why This Episode Matters Now:
In 2022, the war in Ukraine revealed something our partners had been experiencing but we hadn't fully articulated: the traditional model of intact, homogeneous teams wasn't sufficient for the emerging operational environment. Individuals with diverse expertise, geography, language, and allegiances needed to rapidly converge into what we call Tactical Swarms—heterogeneous cross-functional units that form, solve emergent problems, and disperse.
Our recent white paper, The Fourth Generation of Military Special Operations Selection & Assessment, explores this evolution in depth. But six years ago, Preston laid the foundational concepts in this conversation with Coleman.
What the Research Shows:
Many operators who excelled at teamwork—performing with known, homogeneous teams—struggled with teaming: the ability to rapidly build cohesion within heterogeneous groups. This episode examines why routine versus critical communication and field observations across special operations, emergency medicine, and other high-stakes environments. In this episode, Preston and Coleman describe how tactical swarms and X teams differ from traditional team structures, and they distinguish between routine and critical communication and when teams must shift between them.
Recent Research:
- Cline, P.B. (2026). The Fourth Generation of Military Special Operations Selection Assessment: A Community of Praxis [White paper]. Mission Critical Team Institute. DOI 10.13140/RG.2.2.28255.73121. https://missioncti.com/wp-content/uploads/2026/02/The-Fourth-Generation-of-Military-Special-Operations-Selection-Assessment_Final_2-Feb-26.pdf
- Falk, D., Cline, P., Donegan, D., & Mehta, S. (2023). A Novel Framework for Routine Versus Critical Communication in Surgical Education—Don’t Take It Personally. Journal of the American Academy of Orthopaedic Surgeons, 31(3), 115–121. https://doi.org/10.5435/JAAOS-D-22-00912 https://missioncti.com/wp-content/uploads/2023/08/FINAL-A-Novel-Framework-for-Routine-Versus-Critical.pdf
If you find value in this discussion, the best way to support our work and stay up to date on future episodes is to subscribe and leave us a quick rating or review. It helps us reach more people who need to hear these conversations.
This episode contains a term that may be offensive; it is used to describe gendered communication dynamics. We have included it to accurately represent the event, and it is intended for educational purposes only.
Transcript
Welcome to the Teamcast.
2
:I'm Dr.
3
:Preston Cline, director of the
Mission Critical Team Institute.
4
:Here we discuss all things
mission critical teams.
5
:These are teams of four to 12 people,
indigenously, trained and educated, who
6
:solve rapidly emerging complex adaptive
problem sets where the consequence of
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:failure is death or catastrophic loss.
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:With my colleagues and our guests,
we bring you insights from combat
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:zones to emergency rooms dedicated to
improving the success, survivability,
10
:and sustainability of these teams.
11
:We grab.
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:With how to prepare for future
events and how to develop language
13
:and frameworks to transfer critical
off and unspoken knowledge.
14
:Whether you're on a mission critical
team or not, we aim to bring you
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:the broadest range of topics and
guests as possible to help prepare
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:you to perform when it matters most.
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:Thank you for joining us and
hope you enjoy the Teamcast
18
:Welcome back to the Teamcast.
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:I'm Coleman Ruez.
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:Today's topic is routine versus critical
communications and why it matters to
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:certain types of teams, which Preston
will talk about here in a second.
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:Teams called swarms.
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:Teams called X-Teams and why
that's relevant today and why
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:it's frankly relevant every day.
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:So as we get started, Preston,
can we back up for a second for
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:the audience and just go all the
way down to the weeds and define a
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:mission critical team for everybody?
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:Preston: Thanks, Coleman, very much.
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:Mission critical teams...When
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:I first started doing my doctoral
research, one of the things that
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:I wanted to be really clear about
is, is what kind of team they are.
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:There's a bunch of researchers out
there, including Hall, that have
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:done sort of taxonomies of teams
and there's o over in the academic
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:literature, there's over 50 or 60 or
a hundred different kinds of games.
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:Negotiation teams, trauma teams,
special operations teams, and I wanted
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:to be clear that the teams that I
was looking at were very specific.
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:They weren't for everybody.
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:And a big reason for this is because
at the time I was working at the
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:Wharton School in the leadership
program there, and the Wharton School
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:and business schools and academia
have a long history in decision
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:sciences and studying decision theory.
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:90% of that, including Kahneman and oh
many, many others, when they talk about
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:decision making, they're talking about
decision making in an a temporally,
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:unconstrained environment, which is to
say we might make a decision tomorrow,
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:next week, next month, next year.
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:The teams that I was looking
at, that wasn't the case.
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:They were making decisions
in half a second in seconds.
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:And so when we first started coming up
with, and I first started looking at
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:these definitions, I wanted to be sort
of clear in my definition to characterize
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:what was saying, what was different.
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:So it starts off that mission
critical teams are defined as small
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:group dynamics, four to 12 people.
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:And the reason that matters is that small
group theory states that, you know, if
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:you're at a cocktail party and you're
gathering with a group of people and
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:it gets to say into that circle of nine
or 10 people, it starts to split off.
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:It's a natural human condition,
and that's why teams in the
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:military and law enforcement,
they tend to stay in four to 12.
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:Underneath that is a triad or a couple
or a singleton, and those aren't teams.
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:Secondly, you need to know
that a team is not a group.
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:A team is by definition interdependent.
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:You and I aren't on a team
unless I need you to do your
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:work so I can do my work, right?
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:That's the difference
between a team and a group.
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:And so when I say mission critical
teams, you know, part of it is
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:that they're integrated groups of
indigenously, trained and educated.
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:And so again, into the weeds, indigenously
means that you don't go to college
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:to go to the FDNY, you don't go to
college to go to the Navy Seals.
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:You don't go to college
even to be a trauma surgeon.
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:You go to college or not, but you're
going to that organization and the
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:senior gray beards or blue hairs, as
we say, the elders in that community
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:are the ones that determine whether or
not you're gonna make it onto the team.
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:What we call the cadre, the instructor
cadre of the, the communitas, as we would
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:say, or the collection of individuals
that have been through the experience
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:that you're now going through, they're
the ones who can make it sacred, who can
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:actually confirm that you're entering
into their world, their communitas.
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:That's what I mean by
indigenously trained and educated.
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:Trained and educated.
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:I mean by training is for certainty.
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:Education is for uncertainty.
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:We train people for skills.
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:We educate people for thinking.
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:We train people for reactions.
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:We educate people for response.
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:In our world, we train people how
to use a gun, but we educate them on
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:when, where, and why you'd use a gun.
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:And those are actually different things.
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:Your brain learns differently on
how to use your hand or how to
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:ride a bike than it does, how to do
calculus or how to predict the future.
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:Not that we'd ever, are we good
predict predicting the future.
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:Then these teams are focused on resolving
rapidly emergent, complex adaptive
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:problem sets, and it'll be another time
where we talk about problem sets and
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:the theory surrounding them, but just
know this, the only reason all these
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:mission critical teams exist is because.
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:The conventional solutions in the
hospitals and the military and law
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:enforcement encountered a problem
in the fifties, sixties, and
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:seventies, which their conventional
tools could no longer solve.
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:And so they had to create these teams.
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:They had to create seals and SWAT teams
and trauma surgeons, and in command teams.
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:They were necessary because the
problem sets that were emerging in the
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:world required that kind of agility
that a conventional organization
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:just can't do because they need more
predictability than they need agility.
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:And as we've talked about in the past,
when you choose predictability, you
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:trade agility, and when you choose
agility, you trade predictability.
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:And then these folks work in what we
call immersive but constrained five
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:minutes or 300 seconds or less temporal
environments where the consequence of
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:failure is death or catastrophic loss.
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:So the death or catastrophic loss, sort
of self-explanatory, but let me do the
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:immersive and 300 seconds immersive is
for those of you who live in this world.
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:And this is also true by the
way of professional sports.
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:It's true of giving birth.
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:It's true of a variety of things,
but the truth is that the easiest
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:way to understand this is through
the lens of a firefighter.
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:If I'm standing in front of your house and
it's a normal day, I can walk in and outta
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:your house and my reality stays the same.
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:If that house catches fire and I walk
into that same house through that same
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:threshold, I walk into a different
reality, a different space and time.
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:Space moves differently,
time moves differently.
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:It's called an immersion event,
and you enter into it and you
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:have to exit out the other side.
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:You can't stay there, you can't
turn around, you can't press pause.
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:It is what it is.
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:A firefight.
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:A heart surgery.
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:You can't say, you know
what, I'm feeling tired.
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:I'm gonna take a nap
and come back to this.
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:Nope.
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:You're immersed into it like
swimming to the bottom of a pool.
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:You can't pause.
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:You gotta keep going and come back
'cause the air is above the surface and
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:the last thing is 300 seconds or less.
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:Why 300 seconds?
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:Roughly speaking.
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:That's about how much oxygen you
have stored in your brain right now.
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:So you've got about 300 seconds
of oxygen stored in your brain.
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:So if your throat got closed,
right, so you couldn't breathe.
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:We'd have to solve that problem in
300 seconds or less, or we'll start
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:to see cellular death in the brain.
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:A lot of things can be fixed
in 300 seconds and there's
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:more time than you think.
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:In 300 seconds, do yourself a little
favor and start playing around with that.
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:Just do the simple tasks around
your house and time them.
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:How long does one minute really last?
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:And then think about sort of a
chaotic moment and think about
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:how long does a minute last.
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:And this, this actually matters
and it's a good habit to know.
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:One of the universal things, which
I'll close out on this is that no
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:matter how experienced a firefighter
or a trauma surgeon or a special
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:operations personnel that I work
with is none of them can accurately
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:tell time in an immersion event.
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:Michelle Fitzsimmons, the well-
known captain from the FDNY, who
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:is a good friend of mine, she's
actually developed a habit where.
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:She knows how long, roughly, she's
figured out how long it takes for the
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:water to reach the bottom in her boots.
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:She knows how long it takes to stretch
a hose from the hallway to the room,
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:and literally that's how she tells time,
not by telling time, but there's certain
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:markers in the event where because she's
wearing oxygen and they only have 20
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:minutes of oxygen, she needs to have a
rough indication of where her and her
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:team are in terms of oxygen consumption.
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:She's worked out these little cues
to tell her, okay, we're a, we're
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:midway through, we're halfway through.
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:We're a third of the way through, and
that lets her know how to do cadence.
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:That's the definition as I use it, of
mission critical teams as we use it.
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:Coleman: The thing that gets me excited
about any team that has this fluctuation
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:between routine and critical, which
obviously we're gonna talk about
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:today as the primary topic routine
and critical communication, is that
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:we can take someone from the outside,
let's say, who was criticizing the
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:definition, quote unquote, let's say,
well, a firefighter's not always making
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:a decision in 300 seconds or less.
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:That's That's absolutely true.
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:Yep.
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:A hockey team or a soccer team,
or a football team, neither is
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:a trauma surgeon, neither is a
soldier, but the type of team.
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:That is four to 12 in size.
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:That works in a rapidly emergent, complex
environment that does have times in their
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:job where they have immersion events.
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:Those events where once you start
you can't reverse and you definitely
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:don't wanna stay there forever.
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:Preston: Right.
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:Coleman: Football player with a
football isn't running forever.
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:Like they're gonna reach
the end zone eventually.
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:Right.
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:All those conditions exist for.
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:More teams than I think we
would intuitively believe, you
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:know, have those situations.
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:Now obviously we work with a pretty
narrow set, but people can adapt that
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:idea to almost anything in their life.
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:If you have moments where you know
you're in an immersion event and you're
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:making a decision in 300 seconds or
less, just take into consideration
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:some of the topics that are relevant.
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:Preston: If you think about the Navy
seals, if you think about BUDS and
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:basic underwater demolition school,
it's a very storied celebrated and
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:well-documented process that you've,
you instructed in front of, and there's
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:a, there are dual processes going on.
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:The selection of a candidate in BUDS.
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:One is there is a Navy process.
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:There are tests and scores and
predictive analytics, and there's a
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:bunch of things that are necessary
so we don't hurt people, right?
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:And, and we've learned over the years
there are certain rules involved,
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:and those rules need to be upheld and
measured and tested in quantitative ways.
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:We need to put numbers.
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:To paper.
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:There are other things though, Coleman,
that are key to becoming a Navy SEAL
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:that you're never gonna measure.
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:And I'll give you an example.
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:Sense of humor is something that
is reported by all the teams
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:that we study around the world.
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:Rate of learning.
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:Those are the kinds of things
you can't actually measure,
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:you can't put a number to.
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:I know there's gonna be some people in
the audience that say, well, Preston,
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:we actually can measure cohesion.
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:We can measure.
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:And I'm like, not really.
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:I mean, let's be honest.
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:I, I think you're, you're doing your best.
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:But at the end of the day, we can't tell
the weather out seven days ahead of, we
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:can't measure it's human beings for sure.
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:We're incredibly complex individuals
put us in a group and the
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:complexity goes off the charts.
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:And so.
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:I would just say that, that we
should recognize whether you
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:agree with the particulars or not.
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:There's a number of things that
are key to being a member of any
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:tribe, a member of any community.
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:There are certain things we cannot
measure, but are critical, and
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:these are qualitative things, so
the cadre, the, the Navy SEALs
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:who are running BUDS as you did.
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:And I wanna get your
thoughts on this in a second.
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:You have your own criteria,
your own qualitative, tacit,
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:and remember, tacit knowledge.
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:We know how to ride a bike, but we
can't explain how to ride a bike.
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:You after many years, and the seals
know what a good seal was, is, but
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:you may not be able to articulate it.
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:Collectively, you share that belief
system and that unstated tacit knowledge,
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:that shared belief of what right
looks like and what wrong looks like.
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:This is the sort of tacit knowledge
that is held by what anthropologist
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:Victor Turner called the communitas.
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:This is the elders of a tribe who
know the truths of a tribe, who aren't
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:able to articulate it, document it or
quantitate it, quantify it, excuse me.
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:This is as important as the quantitative
information, and this is the key point.
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:They're both important, but they're
valid for different reasons.
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:They use different methodologies, they
use different language, and some of
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:it is really difficult to articulate,
but it doesn't make it any less true
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:in the same way that I love my wife
more than anything else in the world.
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:Could I explain that to you?
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:No, but it's true.
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:And so my habit now is just
to introduce love at every
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:one of our Teamcasts, Coleman.
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:Coleman: I love it.
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:Thanks for doing the explanation.
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:It's amazing when we have group courses
or interactions every time that we
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:present on community versus communitas.
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:There's some head nodding up and down.
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:There's some kill face.
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:There's some eyebrows that go vertical.
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:Preston: Yep.
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:Coleman: It's typically.
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:It's a phenomenal conversation
with whatever team that we're with.
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:Yeah.
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:Because I think if any of us just slow
down for one second and realize how
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:empowering and exciting it is on a team.
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:Preston: Yep.
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:Coleman: When you have this communitas
and paradoxically, when I was an
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:instructor and started thinking about
this more, it's the thing that scared
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:me the most because what I thought was
a good troop commander graduating from
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:our advanced training school could be,
probably not completely different, but
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:potentially meaningfully different in
terms of communitas from the next person.
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:And if the structure of the organization
take an athletic team, for example,
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:the communitas rides on the shoulders
of the coach, the staff, the energy
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:in the locker room, depending
on what the leadership is like.
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:Preston: And you know, one of the
things that we've been brought in
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:from time to time, unfortunately,
is when a team goes sideways, that
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:will happen at the edge of things.
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:These teams are at the edge of things
and , they have high autonomy and
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:sometimes the community, for whatever
reason, there's a bad actor, there's
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:been some bad experiences, there's been
some festering infections socially and
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:they don't get addressed, and all of
a sudden that communitas goes dark.
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:And unfortunately there's not
a lot of easy fixes for that.
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:That's a bad, bad day, and that's why
it's so critically important that the sled
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:dogs, the members of the communitas, hold
each other accountable every day because
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:the consequence of them going sideways.
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:We need them to be highly adaptable,
highly fluid, highly autonomous.
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:And the cost of that is that they
also have to have high integrity.
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:And if they don't, oh gosh, it goes bad.
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:Bad.
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:Coleman: I wanna make one more
comment on this and then we're
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:gonna shift to the key topic.
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:All the great leaders I've ever been
around, they don't always start their
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:opening conversation with a new team,
but you would hear often from them
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:that the only wrong answer is that's
the way we've always done it before.
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:Preston: Yeah.
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:Coleman: Everybody's heard that
at some point in their lives from
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:somebody like this, this is it.
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:Why do we do it like this?
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:Well, we do it like this 'cause this
is the way we've always done it.
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:But if we had the opportunity to
ask the follow on question, well,
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:what's the way we've always done it?
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:You ask the other 30 people on that
team in separate rooms, like almost
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:like a prisoner's dilemma thing?
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:Yeah.
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:If you don't get the same answer from
every single person individually,
302
:you know that you have a misalignment
potentially in communitas, right?
303
:The way things used to be is
naturally it's individual and that
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:great teams don't operate that way.
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:They eventually take the
time, the energy, the effort.
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:To put a shared language to the communitas
portion of what we do, and as painful as
307
:that can be sometimes as the community
knows, especially 'cause of Coronavirus
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:and a bunch of our teammates who are
frontline healthcare responders and
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:doctors, we've just been over energized
with concluding some ongoing research and
310
:collaborations, and it's why we started
the podcast is so we could continue to
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:export some of the things we're seeing
across the entire MCTI community.
312
:And one of those topics is this
idea of X teams, swarms, different
313
:types of teams that have to come
together, that want to come together
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:and the way they communicate.
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:And their communication stove pipes
in a way can be separated in two
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:broad categories, routine situations
and critical situations that require
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:different shifts in our communication
styles, particularly with teams
318
:that are just coming together and
have people that they don't even
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:really know each other that well.
320
:So let's shift gears into that,
Preston, and get your background,
321
:your experience, and some reflections
on, on this recent paper we put out..
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:Sure.
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:So about a year
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:Preston: ago, a little over a year
ago with our friends and partners at
325
:Arena Labs, Brian Ferguson and Dr.
326
:Doug Johnson, we wanted to look at this
question of very specific question,
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:which was, in certain certain hospitals,
in certain surgical units, there's
328
:a number of actors that need to come
together for surgery to be successful.
329
:You obviously have the surgeon.
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:You also have a number of other roles
in that room, the anesthesiologist,
331
:the scrub nurse, and the
circulating nurse among others.
332
:But we're gonna focus on, on those roles.
333
:One of the problems that's happening
right now nationwide, before COVID
334
:was the medical system in the
country is under a great deal of
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:strain and isn't really function.
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:It's really designed to do the things
we're we're currently asking it to do.
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:And we're seeing a lot of friction points.
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:And one of the challenges is, is
that you need to go through certain
339
:roles and sequence in order for you
to get to some of these key roles.
340
:So for example, in surgery, it is
common for you to start as a circulating
341
:nurse before you become a scrub nurse.
342
:That is the nurse that
assists the surgeon.
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:We say a scrub nurse and circulating
nurse, and you probably might envision
344
:the historical roles these nurses
play that you've seen in movies.
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:And what I wanna be really clear
about here is that these are highly
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:trained, really sophisticated.
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:Skills and talented individuals,
these aren't people that show up
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:that morning and learn this craft.
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:It takes years to learn it.
350
:One of the problems is, is that
they need people to come in to be a
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:circulating nurse for a little while
before they become a scrub nurse.
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:And what some hospitals are seeing
is a high attrition in circulating
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:nurses, meaning they're coming in.
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:They're staying for a little
while and they're leaving and they
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:no longer make it the graduate
to the scrub nurse downstream.
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:This has huge negative implications.
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:And so at the time, pre COVID, we were
trying to figure out what was causing
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:this high attrition for circulating
nurses, and there are a number of
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:variables in play here, but we were
focusing on one specific one, and the
360
:premise was pretty straightforward.
361
:The belief at the time
was doctors are jerks.
362
:And this has been reinforced by a
number of people, including doctors and
363
:nurses, that there's some truth to this.
364
:And the belief was is that doctors, for
a variety of reasons, lack a certain
365
:amount of empathy, and in that lack
of empathy are rude and obnoxious and
366
:critical of nurses and drive them out.
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:This was the assumption, right?
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:And so I had been asked to walk
into this particular hospital and
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:observe three surgeries in a row,
happened to be heart surgeries.
370
:And the heart surgery,
it lasts for three hours.
371
:And this is important, and I'm gonna try
to describe this to you over the radio
372
:in a way that you both understand the
theory, that it underpins it, but also
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:the actual lived experience of that event.
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:So the first thing you need to know,
theoretically, is that heart surgeons
375
:specifically are hybrid teams.
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:And here's what I mean by that.
377
:They're typically intact teams,
meaning that they're the same
378
:people that work together.
379
:Day in, day out.
380
:So they get to know each other,
build trust and cohesion.
381
:The second thing you know, the reason we
call them hybrid teams is because if, for
382
:example, on average heart surgery lasts
three hours, that roughly the first hour
383
:is a routine surgical event, which is
to say, we're kind of making the donuts.
384
:Everything is gonna be done
by a checklist as a tool.
385
:Gawande talks about in his research, and
I recommend his research, is he got great
386
:books and the first hour is routine.
387
:You know, you, you're gonna clean
them up, you're gonna, you're gonna.
388
:Get all the stuff sorted out.
389
:Everybody's gonna do the things and
the, and you're having this normal
390
:kind of a conversation, and then an
hour in, you're gonna switch that
391
:person over onto the heart lung
machine to keep them alive while
392
:you're messing around with their heart.
393
:That's my technical term, messing around.
394
:What will happen though, is once
you turn on that heart lung machine,
395
:you have a statistical time limit
before the likelihood of that person
396
:getting a blood clot in their brain
because of the heart lung machine
397
:goes very high, like scary high.
398
:So you're gonna open up the chest on that
mark when you cross 'em over and you're
399
:gonna turn on the heart lung machine.
400
:And then basically you have
say 45 minutes to an hour to
401
:solve whatever problems show up.
402
:So whether or not you didn't see
something on the scans, whether or
403
:not a mistake is made, it all has to
get solved at 45 minutes to an hour.
404
:And so what ends up happening is
you move from this checklist driven,
405
:conventionally minded routine surgery
into what is more akin to trauma surgery.
406
:Yes, there's checklists.
407
:Yes, all that stuff is still true,
but there's also high agility,
408
:high innovation, high adaptability.
409
:And then once you put them back on
the heart and get the heart restarted,
410
:you go into closing procedures
and you're back up into routine.
411
:So the final hour is routine.
412
:So imagine that you have a team,
an intact team that is going from
413
:routine to critical, back to routine.
414
:Stop, pause, take a break, go
routine, critical, back up to routine,
415
:pause, wrap, and then do it all over
again three times during that day.
416
:You should know that in a hospital
you have typically personalities that
417
:will gravitate towards trauma because
they like the critical environment.
418
:And you have people that will gravitate
towards traditional surgery or
419
:wards because they like the routine.
420
:It's very actually hard to find people
that can do both and do both well.
421
:And so they're an interesting team for
a person like us to examine because they
422
:demonstrate skills and abilities that
are often not seen in the same team.
423
:So in this particular case, I'm there
because I'm sitting in the room and
424
:my job is to observe the behavior,
the communication amongst the team
425
:to see where we can do a better job.
426
:Teaching doctors empathy, and
that's the idea behind it.
427
:Where are some inroads that we can
make with doctors to give them better
428
:sensibilities around empathy and, you
know, good on them because it was the
429
:doctors that actually asked for this, and
they were the ones that recognized they
430
:could be doing a better job at the time.
431
:That was the assumption.
432
:And there's some caveats here.
433
:I'm not making blanket statements,
just this particular phenomenon.
434
:So I sit there and, and in the first
hour, the first three hours, the
435
:first surgery, you hear things like,
I love you and thank you, and you're
436
:awesome, and oh, we're excited to see
you, and you're doing a great job.
437
:It was one of the most inclusive
and supportive working environments
438
:that I'd seen in a long time.
439
:It wasn't the team room
in special operations.
440
:Coleman: I never heard those things.
441
:Preston: Yeah, exactly.
442
:And so this was this, I was sort of,
my head was scratching, like, I'm not
443
:tracking, are they performing for me?
444
:What is happening right now?
445
:Just let me paint the picture of the
environment that we're looking at
446
:in these kind of surgical events.
447
:You're looking at a room and
I'll try to describe it to you.
448
:It's the room, maybe the size of a
classroom, maybe a little bit smaller than
449
:the classroom that you went to school.
450
:The center of the room is empty,
but on the ceiling hanging from the
451
:ceiling is a series of monitors all
angled in a sort of 360 kind of.
452
:A situation that would basically sit
above where they're gonna roll the
453
:patient into, they roll the patient into
the center of a room where there is a
454
:big circle that's painted on the ground,
and we're gonna call that the bubble.
455
:Okay.
456
:The patient gets wheeled into
the bubble and then the sort of.
457
:Technical ecology, the ecosystem,
the technical ecosystem,
458
:it's built around them.
459
:First comes the surgeon who
says, hi, my name is so and so.
460
:You're here to get heart surgery.
461
:Do you want that?
462
:Or Are you here for an appendix?
463
:And that gives them an
opportunity to go, no, no, no.
464
:I just sprained my leg.
465
:I don't need open heart surgery.
466
:That doesn't happen, really.
467
:And so they say, yep, that's me.
468
:And they said, great.
469
:And then we're gonna introduce
you to the anesthesiologist.
470
:The anesthesiologist then rolls in
all their equipment around the head.
471
:Proceeds to put the person under,
and then the rest of the technical
472
:ecosystem gets literally rolled into
and around the patient and they build
473
:this sort of technical ecosystem
or this bubble around the patient.
474
:So you have the room, and the room
is managed by the circulating nurse.
475
:Nobody gets in or outta the room.
476
:That's a circulating nurse managing that.
477
:Then inside the bubble you have the
scrub nurse and that nurse, male
478
:or female is standing on a platform
that gets wheeled over the patient.
479
:So they're a good head or shoulders
above everybody else, and that
480
:way they can own the bubble.
481
:So the scrub nurse owns the bubble,
the circulating nurse owns the room,
482
:and they interact with each other.
483
:That's how I saw it.
484
:Probably surgeons might be more
specific than I am, but I'm
485
:trying to tell a story here.
486
:And so I'm watching all this
happen, and it's amazing, actually.
487
:It's extraordinary.
488
:And then you gotta remember that even
though I've been doing this for a long,
489
:long time, I'm still a human being.
490
:I'm 50 years old and I'm in the
corner trying to stay outta the way.
491
:And I've been in many team rooms
around the world looking at elite
492
:teams, and I pride myself on
staying outta the way of shutting
493
:up, of not interrupting their work.
494
:I'm there to observe and not
to intrude, not to be noticed.
495
:So in between the first patient and the
second patient, some of the, the medical
496
:personnel in the room and in the hospital
heard I was in the building and wanted
497
:to ask me on a break about my research,
what I was finding, why I was there, all
498
:that sort of stuff they had heard about.
499
:And I was like, yeah, sure, of
course I'm a guest in your house.
500
:So they're asking me these questions
and I'm answering it because I'm old
501
:and there's all this ambient noise.
502
:I'm speaking loud like I am right now.
503
:Right?
504
:Like Coleman and I get
feedback on, I speak too loud.
505
:In that moment, the anesthesiologist
steps out from behind the patient who
506
:is the second patient who is putting
under to have open heart surgery.
507
:This person's probably terrified and
says in the nicest, kindest way, Hey,
508
:Preston, can you and he, and he puts
his hand out, like to turn a dial and
509
:he says, Hey, Preston, can you dial
your voice down just a little bit?
510
:I'm still putting the patient down.
511
:Now if I was him, Coleman, I gotta be
honest with you, I would've just thrown
512
:me outta the room like I would've chewed
me out and thrown me outta the room
513
:like, this is open heart surgery chump.
514
:Like this is not a time for you
to be having cocktail hour talk.
515
:But here's the thing, Coleman,
as I mentioned before, I have
516
:pride in my practice and I've
been doing it for a long time.
517
:My inner monologue at that moment right,
is the toilet bowl spiral of death, of
518
:shame and embarrassment and recrimination.
519
:I am upset at myself.
520
:My wife should leave me.
521
:I should just be homeless.
522
:I have failed.
523
:Everyone failed him.
524
:I failed the, my hosts, I failed
the patient who I don't even know.
525
:And then also there's the
12-year-old boy in me like.
526
:Hey, who's that doctor?
527
:What, how are you talking to me like that?
528
:And then there's my grandmother's voice,
like, how dare you insult a doctor, right?
529
:And then I'm like, I'm sorry.
530
:You know, to my grandmother,
all of this is happening in my
531
:head in 15 in seconds, right?
532
:It's just a crushing weight of despair.
533
:And then of course, the
grownup in me is like, whoa.
534
:Press and press and pressing press.
535
:He, he's probably already
forgotten about it, right?
536
:You have a thick skin,
he's gonna get over it.
537
:If he really wanted to throw
you outta the room, he would've,
538
:no one's in the wrong here.
539
:Get it together and fix it.
540
:And I was like, okay, thick skin, right?
541
:And then I have this moment, this
sort of epiphany, and I go, hold on.
542
:I'm here studying doctors, because
our belief is they're transmitting
543
:in a way that lacks empathy.
544
:But that doctor, that anesthesiologist,
just gave me feedback in the
545
:most empathetic way possible.
546
:And it was all about how I received
the information, not how it was
547
:transmitted, how I received it.
548
:I'm trained to receive feedback from some
of the meanest people in the world, right?
549
:Like the harshest people in the world.
550
:I can take feedback regularly,
like, thank you very much.
551
:Write that down and take a look at
it without getting my feelings hurt.
552
:So what just happened and how,
what do I mean by thick skin?
553
:And so my brain gets to be like a
hamster on a wheel when this happens,
554
:when I discover some phenomenon,
I can't explain for myself that
555
:I have no framework to explain.
556
:And so then I become this creepy
observer and I start looking at the micro
557
:expressions of all of the nurses and the
staff in the room for the next six hours.
558
:And here's what I find when a surgeon is
using a tool and they ask their nurse for
559
:a tool or another tool, and let's say,
because it's very subtle, these stuff,
560
:it's, it's very precise, it's very subtle.
561
:And they say, Hey, I need this tool.
562
:Or, Hey, no, not that one.
563
:The other one.
564
:Well, if you have pride and you work
and you think you're good at it,
565
:that can be really startling for you.
566
:'cause you like to pride yourself.
567
:Like I should have given him
the right one to begin with.
568
:He shouldn't have to
tell me the other one.
569
:And so, how do we manage this
feedback, which we think, you
570
:know, we're feeling emotionally,
but it's not emotionally charged.
571
:It's not intended to be emotional,
and yet we're receiving that.
572
:So I started, when I left there, I
was obsessed by this concept and I
573
:started reaching out to some of the
like most thick skinned, roughest,
574
:harshest people I know and go,
how did you learn your thick skin?
575
:And they were like, yeah, I got beat up.
576
:Like a lot and people just
told me, I gotta get over it.
577
:Don't take it personally.
578
:All these things.
579
:And some of it, honestly, you know,
people don't like to talk about the toxic
580
:masculinity stuff because people, it's
like a trigger word for people these
581
:days, but there's some trick to it.
582
:There's some stuff in male and female
culture both that isn't helpful.
583
:Right?
584
:And some of that is about how
we learn to take feedback.
585
:And so we came up with this idea,
which is what if we, what if we
586
:actually were intentional about it?
587
:What if we took some people.
588
:Before they were ever entering into
this world and explain to them using a
589
:model very, very briefly, here's what
routine communication sounds like.
590
:Respectful, courteous, kind.
591
:Right?
592
:We all agree on that.
593
:And, and in a 302nd environment
where the consequence could
594
:be death, you's what Critical.
595
:You know, if your child is hurt, you don't
want people asking you a lot of details.
596
:You want people to be direct,
monotone, factual, and fast, right?
597
:Let's get this fricking thing done.
598
:If you walk into a room and this is
the aha moment and you don't know me,
599
:and I see a threat you can't see, and I
turn to you and I start speaking to you
600
:in a critical communication framework.
601
:I sound like a jerk.
602
:I sound mean, I sound insensitive.
603
:But the truth is, I'm
trying to keep people alive.
604
:I don't see you.
605
:I see you as a role.
606
:I see you as a means
to keep somebody alive.
607
:I don't see you as a human.
608
:And when we started saying that to people,
to new staff, a lot of them were like, oh.
609
:Oh, they're not mad at me.
610
:They're not even mad.
611
:They're not even talking to me.
612
:They're just talking to the
person in my role, and they
613
:need a thing from that person.
614
:And they didn't, it
wasn't the right thing.
615
:They just need the other thing.
616
:That's it.
617
:That's all of it.
618
:And I'm like, yep.
619
:And so, one last thing on this
because it's really interesting and
620
:it's something I learned at Wharton.
621
:This is not in the paper.
622
:So at Wharton we went through a
period where I had 30, what are
623
:called venture fellows, which are
second year MBA students who helped
624
:me lead expeditions around the world.
625
:And one of the questions that was asked of
us was, how do we develop female leaders?
626
:And the first thing I was
like, well, I don't know.
627
:I'm a guy so I know I'm already gonna
suck at that, but I want to be better.
628
:I definitely want to be better
and I want for young women to be
629
:better having spent time with me.
630
:So what don't I know?
631
:What can't I see?
632
:And they, they did a skit for me
and it was like, it's never left me.
633
:And they called it the red
pants skit, and here it is.
634
:They put a bunch of dudes, a bunch
of guys on stage, and they had a guy
635
:walk in wearing red pants and all
the guys were like nice red pants.
636
:And then they asked the
audience, what did the guys mean?
637
:And everybody was like, they
were making fun of his red pants.
638
:Everybody was clear on that.
639
:So then they kept all the guys on
the stage and they put all the women
640
:on the stage and they had a woman
walk in with red pants and they had
641
:all the women say nice red pants.
642
:We asked people what they meant
and all the guys were like, well,
643
:they were complimenting the pants.
644
:And what the women explained to
us was they meant everything from.
645
:Those are really nice pants to, you're
a slut to, I think you look fat.
646
:All of us guys were like, whoa.
647
:That's all in the nuance.
648
:And they're like, that's our
lived experience every day.
649
:So that gender dynamic, which I'm
sure I'm destroying somehow and
650
:someone will correct me, but it was
this huge awareness for me that there
651
:were colors of the rainbow I was not
seeing in day-to-day communications
652
:that I just as a guy was not aware of.
653
:And so when you look at their very
real gender dynamics in hospitals, for
654
:example, this is one of the things in
critical and routine conversations that
655
:needs to get addressed and needs to get
addressed by people smarter than I am.
656
:But what we can do is amplify that.
657
:It's a thing and we need
to get better at it.
658
:Coleman: So thank you for that.
659
:First of all, Preston, second of
all, you and I are not qualified too.
660
:Make any comments on gender
dynamics, communication styles.
661
:That's right.
662
:But it just made me think what we
should do for the community is bring
663
:a Michelle Fitzsimmons or somebody
from our community, Holly Ridings as
664
:a guest, just to continue this thread.
665
:Yeah.
666
:You know, in terms of routine
and critical communication.
667
:I just wanted to add one note as an
amplification, because if you really
668
:slow down and think about this concept
in your own life, it's easy to pick
669
:out places where you saw somebody
go from routine to critical and
670
:you sort of took it the wrong way.
671
:Right?
672
:Or I know there's thousands of
places that I went to critical,
673
:either too fast or intentionally,
and it wasn't set up properly.
674
:So I have this memory hit me.
675
:Years ago when we were co-teaching a
course at the graduate school there.
676
:And when we were on this topic, my
first platoon commander at Seal Team
677
:three, he passed away from complications
around a brain tumor that he got
678
:later when we were in the teams.
679
:But a fantastic guy.
680
:And I remember when I was brand new at
the team, you know, contrary to people
681
:who are outside the military who may
not realize, you know, contrary to
682
:popular belief, it isn't this super
rigid chain of command, and particularly
683
:in a special operations platoon.
684
:And there's a lot of
flattening of the team.
685
:People who are very junior get
a significant amount of input,
686
:certainly compared to what you
see just in a regular business.
687
:Very junior.
688
:You know, folks in a special operations
team have a lot of say, and so we were
689
:going through this training cycle for a
couple of weeks before going on deployment
690
:and as platoon commander of ours.
691
:He had a really good style, like
always taking input, always taking
692
:input, always taking input and
applying it where he could and taking
693
:everybody's notes and suggestions.
694
:And there was one training trip
we were on, and I remember at
695
:the time very uncharacteristic
of him, but he kind of like.
696
:Cut everybody off, made
a series of decisions.
697
:We went into this field training
exercise that we call FTX.
698
:It didn't take two hours for a
little bit of rumbling in the platoon
699
:to start like, what the heck is
wrong with, you know, so-and-so?
700
:What the heck is wrong with so-and-so?
701
:And he obviously picked up on it.
702
:He wasn't stupid.
703
:Later, three days later, when this FTX is
over, and this was one of my first, what
704
:I consider not the garbage you list, you
learn in like leadership 1 0 1 courses.
705
:My first real tactical lesson of
blending the art and science of, you
706
:know, of leadership just in general.
707
:He sat the whole platoon down and he
said, look, someday you're gonna be
708
:a boss of something and you're gonna
have a thousand things pulling on you
709
:to include temporal constraints, right?
710
:Just pure time constraints.
711
:I've tried to do a great job of taking
everybody's input when I have the time
712
:and as much as possible, but there are
periods of time and most of the time it's
713
:gonna be when we're compressed for time,
I'm gonna make a decision fast and quick
714
:and I need you just to listen and do.
715
:Right, and what he was saying, Preston
obviously was he was seeing a thing or
716
:dealing with a thing or had some sort of
context that the rest of us didn't have.
717
:And what I've since learned is the one
thing missing in that, that I think
718
:is a freaking superpower of great
teams is the rest of us didn't know.
719
:When he was making the transition
from routine to critical, but
720
:in the future we kind of did.
721
:You know, it wasn't something he called
out using this language, but if you
722
:think about athletic team, coach,
doctor, platoon, commander, you name
723
:it like a pilot on the radio, right?
724
:We're flick-flacking between
routine and critical.
725
:And sometimes the team, until they
really know our personality, they just
726
:don't know when we're switching modes.
727
:Preston: You know, one of the really
fascinating things, Coleman, is what
728
:you just mentioned, is how many people
are like, well, how do they know
729
:when I move from routine to critical?
730
:They figure it out.
731
:Well, okay, but we are now, and the
reason that we wrote this article, and
732
:we reason that this is so important right
now is, let's go real time for a second.
733
:We've got traditional intact teams in
medicine right now, frontline medicine.
734
:Are being asked to go on what are
called swarms or X teams, where they
735
:are deployed to work with a team they
may, may not have met before to rapidly
736
:figure out something to resolve,
something to keep somebody alive.
737
:We actually don't have time.
738
:Anyone more for the team that
you may not be working again
739
:with Again, to figure it out.
740
:We have to do better than that.
741
:Those old sort of
solutions where Oh, yeah.
742
:You know, well, they'll
just figure it out.
743
:No unacceptable.
744
:We have to figure out a way that we need
to put in place early on to help our teams
745
:know when we've made that transition.
746
:Coleman: Yeah, for sure.
747
:And as importantly, when I think about
just regular non frontline healthcare
748
:workers dealing with what they're
dealing with today, which is just
749
:like a combat deployment for them,
but typical day-to-day things, even
750
:outside of a crisis environment, a
team can really, they don't have to.
751
:Make it this big, huge thing
where you send up a red star
752
:cluster, you know Right.
753
:When you're going into critical,
that's not what we're saying, but if
754
:teams know each other's style a little
bit better based on the things that
755
:they typically deal with, you can
just get more out of each other, and
756
:that's a great thing for any team.
757
:Preston: Our mutual friend, Harry
Moffitt, who's a bit of a legend in
758
:this world, one of the things I was
last year down in Australia with him.
759
:And one of the things that he did with
his family and did with us, my wife and
760
:I, he said, Hey, look, if there's ever
a situation where you hear me say, and
761
:he said this literally as we were just
walking through the Melbourne, he said,
762
:if you ever hear me say with me, just with
me, just get behind me and go where I go.
763
:I thought it was just genius
because I'm in a foreign city.
764
:I really don't know what's happening.
765
:I don't know what he
sees that I don't see.
766
:It was great because I immediately
knew what to do and I immediately
767
:knew why he was switching, sort of
his communication style, and for me
768
:that little expression was awesome.
769
:Coleman: Preston, let's, for the
community, one of the things we're gonna
770
:do is we come to the end of each segment.
771
:We're going to always try to close
out with what to do on Monday.
772
:It's important to us that the guests
that we have on in the future, the
773
:topics that we discussed, that there
isn't just some, oh, good luck that
774
:we drive all the way back down to
practical applications and some tactics.
775
:So for the listeners, Preston, with
respect to routine and critical
776
:communications or respect to anything
you want, what's a recommendation or
777
:a tactic for what to do on Monday?
778
:Preston: So here's some things
that we found really easy
779
:to do and really successful.
780
:Get your team together if you can, and
we'll go for right now with Intacct
781
:teams and we'll talk about non-intact
teams, swarms and and X teams.
782
:But let's start with intact teams.
783
:Get your team together, have
everybody write down that if they were
784
:gonna go into their boss on Monday
morning and have a meeting about,
785
:you know, their future employment.
786
:They wanted the meeting to be
congenial and to be relaxed and fun.
787
:What are your five principles?
788
:Have 'em write that down and then
share them together and you'll
789
:find there's a lot of overlap
and everybody can nod and agree.
790
:Okay, we all agree that courtesy,
respect, active listening, those
791
:are, those are important things.
792
:Then do the same thing.
793
:Okay, we've got, we've got an emergency,
we've got a crisis, 300 seconds or.
794
:Write down your five things and you're
gonna find clear, concise, direct.
795
:You're gonna find overlap there too.
796
:And if you do those things, you
can help everybody understand
797
:what the difference is, right?
798
:And then what you have to think
about is how are you gonna
799
:communicate to each other.
800
:When you're gonna have these environments,
when you're gonna make these changes.
801
:So if you are in an environment that
you can control, like surgery, there are
802
:literally things, simple things like have
music playing, and when the music turns
803
:off, everybody switches to critical.
804
:It's in the ambient environment.
805
:That's the signal everybody put your
game face on, we're getting into it.
806
:And then when the music comes
back on, take off your game
807
:face, we can relax a little bit.
808
:Right?
809
:Or if you don't have technology, right?
810
:Radio beeping, a visual
display or something like that.
811
:Think about expressions.
812
:The Marines have a great
expression of eyes.
813
:I dunno if this is true in the Navy
or as well, but this idea, if somebody
814
:yells at eyes, literally, that
means everybody should look at them.
815
:Your eyes should look at them
and they'll tell you what to do.
816
:But it's a great thing because it's quick
and to the point, eyes or ears, right?
817
:And some communities that might
be too abrupt with me is lovely
818
:or whatever, some sort of cue.
819
:You can make it up for yourself and it can
be fun and it can be unique to your team.
820
:There's been research done by, again,
Atul Gawande and others to show something
821
:as simple as introducing yourself.
822
:Wearing a name tag, shaking
someone's hand, or appropriate
823
:physical touch can go a long way to
help cross some of these divides.
824
:And so they're subtle, but they're
powerful because at the end of
825
:the day, to go back from what we.
826
:We talked about the
very beginning of this.
827
:We're talking about
community and communitas.
828
:We're talking about rules.
829
:We're talking about tribe.
830
:You could have rules, but you have to
remember we're still part of a tribe, and
831
:the tribe has its own sort of way of doing
things and you have to account for that.
832
:Coleman: Was there something on X
teams and swarms you wanted to add?
833
:Preston: Yeah, so just really briefly, and
I, and I'll be more specific about that.
834
:So in a situation where, in the
classic example in medicine is on a
835
:resuscitation, somebody has coated
their heart, has stopped breathing, and
836
:basically a group of people will have
their phones or their beepers go off
837
:and they'll swarm to the patient and
they'll each have a role and they have
838
:to execute that role quite quickly.
839
:They don't have a lot of time.
840
:There's not a lot of time to sit around
and being like, hi, my name's Preston.
841
:How are you?
842
:Gemini, that's not gonna work out right.
843
:But what you can do is you can have
certain things done ahead of time where
844
:if you know the people that will get
pulled into a code, if you know the people
845
:who might join your team at some moment
to reach out to them prior to the event
846
:and literally just introduce yourself.
847
:Say, Hey, my name's Preston.
848
:Shake their hand physical touch.
849
:Say your name, say their name, and
you'd be surprised what can happen.
850
:And then let them know, Hey, in these
environments, here's the difference
851
:between routine and critical.
852
:In a resuscitation, we will
always be seeking critical.
853
:If I see any behavior that I don't
think is good, what I'll do is after
854
:the dust settles, I'll swing back
around to you in a routine environment
855
:over coffee or tea or water, and then
I'll gently sort of say, Hey, look.
856
:For you to move towards your potential.
857
:Here's some things to consider,
and that's the way you give
858
:feedback around those things.
859
:But you can't do it in the moment.
860
:You can't receive feedback in the moment.
861
:It's not useful.
862
:Coleman: Thanks for that.
863
:Preston, for the community, keep in
mind, doctors, first responders, nurses,
864
:frontline healthcare workers, especially
during this time or literally on a
865
:deployment, a domestic deployment.
866
:So to the extent that you can be.
867
:Helpful to them.
868
:Try to do so.
869
:Thanks for the time today.
870
:As usual, Preston,
871
:thanks for listening and
talk to you next time.
872
:Preston: Thank you again for
listening to our Teamcast.
873
:If you found value in this discussion,
the best way to support our work and
874
:ensure you don't miss future episodes is
to describe and leave us a quick rating
875
:or review and help us reach more people
who need to hear these conversations.
876
:For more on Mission Critical Team
Institute, including all of our episodes
877
:and show notes, visit missioncti.com.
878
:You can also connect with us on
LinkedIn, and if you're a mission
879
:critical team looking to learn more
about our programs, reach out directly
880
:to our director of Operations, Ms.
881
:Janese Jackson at janese@missioncti.com.
882
:That's j-a-n-e-s-e @missioncti.com.
883
:Until next time, thanks.
