Point of the Wedge: Professional Services Firm

At a US-based professional services firm, junior employees were taking too long to learn the ropes. Working behind the scenes, feeling underutilized, they rankled at what they saw as lack of opportunity.  At the same time, senior people were spending less and less time coaching and mentoring as they bore the burden of daily operations.  Both groups ultimately wanted the same thing, but sometimes seemed to be working at cross purposes.

At the firm’s request, Duke CE helped them examine a new development model to facilitate coaching and accelerate learning.  It began with a seemingly simple question: could the learning methods of teaching hospitals—where the least-experienced team member makes crucial presentations and decisions—be of value in the business world?  Teaching hospitals champion the Socratic Method: teaching by asking rather than telling.  They “round” in teams.  They factor in mistakes while preventing them from affecting patients.  And most obviously, and most critically, teaching hospitals value coaching. Could their methods, demonstrably effective for medical residents, facilitate learning in industries other than healthcare?

At first glance, hospitals and professional services firms seem worlds apart.  Yet parallels abound:  fast-paced technological advances, the rapid and constant influx of new information, time pressure and economic pressure, and a high-risk, high-stress, highly regulated environment.

The most visible and influential learning method in teaching hospitals is team-based learning, in which all members of a hierarchical team contribute to the investigation and eventual solution of a problem.  A medical team typically consists of students, interns, residents, attending physicians, nurses, and often social workers and patient case managers—individuals at different levels with different areas of expertise.  As they work, feedback is given continuously, not just in formal performance reviews.

Medical rounds, another crucial element of the learning system within teaching hospitals, combine team-based learning with problem-based learning, in which a team rallies around a particular problem (a patient’s health concern) using debate and dialogue to conceptualize it and develop solutions—a diagnosis or treatment.

During medical rounds the youngest and most inexperienced team member—often an intern—speaks most often, presenting a diagnosis and potential treatment plan. When grilled, they confidently offer relevant information, showing their degree of preparation.  Nevertheless, as a result of the ensuing dialogue they often end up rethinking both the diagnosis and treatment.

“Owning the patient” as the least experienced team member is what Dr. Charles Wiener of Johns Hopkins Hospital calls being “at the point of the wedge”.  Dr. Wiener, who runs the residency program, encourages interns to prepare vigorously to present a patient, calling on resources as needed to contribute to improved patient care—and not incidentally forcing the intern to develop an informed point of view.  Over time, presentations to the team enhance communication skills, instill confidence, and deepen an intern’s medical knowledge. In spite of the intense pressure to perform, interns feel comfortable knowing that their entire team—the “wedge” —will support, correct, and coach them. And in fact every member of the medical team, at every level, may learn something new from any given case.

“If you are the one who feels responsible for that patient’s welfare, it makes you be very honest with yourself about what you do know and what you don’t know,” says Dr. Wiener. “It makes you more willing to ask questions because you know that, by not asking a question, you may impact someone’s health.”

In the best teaching hospitals, like Wiener’s, even mistakes are considered fodder for learning. During medical rounds, teams openly and non-punitively discuss mistakes and how they might be avoided in the future. Formal errors conferences review hospital-wide “morbidity and mortality”, allowing staff to acknowledge and learn without blame.

By valuing both patient care and learning, teaching hospitals have created an environment in which new and seasoned physicians alike learn continually and rapidly in the context of daily work. Through team-based and problem-based learning, individuals improve interpersonal and technical skills simultaneously.  Coaching is constant and pragmatic, feedback a routine matter, and mistakes a wake-up call and opportunity to drive change rather an occasion for finger-pointing.

There are caveats for business applications, though:  team meetings and presentations take longer given the need for feedback and dialogue, and patience is required of high-ranking (and costly) experts.  In the corporate setting, if managers fail to appreciate the need for a learning culture, there will be friction within the team.

Nonetheless, the professional services firm that had sponsored the research recognized many potential benefits, not least of which was that young employees would learn faster.  With some adaptation to their corporate culture, they were able to apply lessons from teaching hospitals, including the introduction of “rounds” and errors conferences.  They created immediately relevant, accelerated, and cost-effective learning for employees, improving client service and enhancing the satisfaction and retention of young team members.