Citation
Interdisciplinary/interprofessional teamwork

Material Information

Title:
Interdisciplinary/interprofessional teamwork
Creator:
Illingworth, Linda Catherine, 1950-
Copyright Date:
1983
Language:
English

Subjects

Subjects / Keywords:
Anthropology ( jstor )
Applied anthropology ( jstor )
Cogeneration ( jstor )
Cultural anthropology ( jstor )
Health care industry ( jstor )
Medical anthropology ( jstor )
Nurses ( jstor )
Physicians ( jstor )
Social sciences ( jstor )
Subcultures ( jstor )

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
11412072 ( OCLC )
ACK8350 ( LTUF )
0030325092 ( ALEPH )

Full Text















INTERDISCIPLINARY/INTERPROFESSIONAL TEAMWORK:
SOCIO-CULTURAL AND PSYCHOLOGICAL DETERMINANTS
OF TEAM CONFLICT





By

LINDA CATHERINE ILLINGWORTH


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1983
































Copyright 1983

by
Linda Catherine Illingworth






































For
Lorne















ACKNOWLEDGEMENTS


I owe a debt of gratitude to many people for their

assistance in the completion of this dissertation. I wish

to thank Dr. Otto von Mering for his guidance and advice

throughout my graduate career at the University of Florida.

As my advisor he was particularly kind, patient and helpful

as I pursued the dissertation. Our association has always

provided me a rich source of intellectual stimulation. I

also wish to remember Dr. Elizabeth Eddy for her unfailing

encouragement and for her appreciation of my potential. She

was an invaluable source of support to me. Yet another

individual important to my education was Dr. Paul Doughty,

who provided a model in work as in deed.

I also wish to thank the members of my committee, Dr.

Ronald Cohen, Dr. Robert Lawless, Dr. Paul Magnarella and

Dr. Charles Mahan for their time and consideration. Judith

Lisansky was generous with friendly editorial and organiza-

tional assistance when I was working on early drafts of the

dissertation.

Finally, I wish to thank my close friends, Denise Weiss

and Ada Dzieszuk-Gilman. They have always encouraged me in

everything I do, as have my parents, Larry and Cathy


I









Illingworth. I want them to know that I appreciate the

thoughtful care they devoted to raising and educating me.

Most important in all of this has been my husband, Lorne

McWatters, my constant companion and very dearest friend.
















TABLE OF CONTENTS


PAGE

ACKNOWLEDGEMENTS ........................................ iv

ABSTRACT ....... ...... ................................ ix

CHAPTER

I INTRODUCTION .................................... 1

Review of the Literature on Teamwork............ 7
Definition of Teamwork ........................ 8
History of Teamwork Literature .............. 12
Interdisciplinary research teams .... ....... 12
Interprofessional clinical teams ............ 14
Interdisciplinary/interprofessional teams... 18
Applied Anthropological Research ..... ....... .. 20
Subcultural Analysis of Teams .. ................ 23
Critique of Non-Subcultural Analysis of
Teams....... ................................ 23
Treatment of Medical Dominance in Team
Literature ................................ 25
Critique of Earlier Subcultural Analysis of
Teams ....................................... 27
Summary ......................................... 29
Notes ............................. ............. ..42

II TEAM HISTORY AND FIELDWORK SETTING.............. 45

CHP Team History... ............................. 46
Field Setting ................................... 50
The First Anthropologist ........................ 55
The "New" Social Scientists .................... 58
Summary ................................ ........ 61
Notes .... ....................................... 62

III THE CHOICE OF METHOD OF STUDYING TEAM
FUNCTIONING .......................... ........ 65

Qualitative Evaluation Research.................. 65
Context ........................ ............. 65
Sample Size ....... ............................ 68









PAGE


Goal Definition ............................... 68
Research Implementation ....................... 69
An Overview of the Fieldwork Situation and
Data Generation of the CHP Team............... 70
Summary ... ..................................... 76
Notes ........................................... 77

IV TEAM SUBCULTURES AND MEDICAL DOMINANCE IN THE
CHP TEAM ...................................... 79

Medical and Social Science Subcultures in the
CHP Team ..................................... 82
Medical Dominance in the Health Services........ 87
Physician and Medical Dominance in the CHP
87
Team.................. .................... .. 87
The "Real" and the "Ideal" Program............. 96
104
Summary ..... ................................... 104
Notes.................... ....................... 106

V THE "SECONDARY" STATUS OF SOCIAL SCIENCE IN
THE CHP TEAM .................................. 108

The Physician's View of the Place of Social
Science in Team Operations ....................110
Nurse Practitioner Adversarial Perceptions
of Social Science in Health Care Practice..... 112
Historical Antecedents of Hiring Social
Scientists on the CHP Team.................... 120
The Predecessor of the Social Scientists........ 123
Social Science Reaction to the Reality of a
Non-Egalitarian Team...........................126
130
Summary ..... ................................... ...
131
Notes ........................................... ..

VI SUBCULTURAL DIFFERENCES AND ROLE CONFLICT ...... 133

Subcultural Differences.......................... 134
The "Typical Day" of the Clinical and
135
Research Subcultures..........................
137
Goals.................... ..................... 137
Values....... .......... ..................... .. 147
149
Role Conflict ................................... 149
Critical Role Conflict I: Social Scientists
as Unwitting or Unwilling Social Workers
and Fund-Raisers ............................ 149
Critical Role Conflict II: Social Scientists
as Program Advocates and Public Relations
153
Representatives...............................
160
Summary....................................... ..160
Notes................. .............................. 163


vii








PAGE

VII THE IMPACT OF PERSONALITY, GENDER, ETHNICITY
AND SOCIAL CLASS ON THE CHP TEAM.............. 168

Personality.......................................... 169
The Blaming of CHP Team Conflict Upon
Individual Personality....................... 170
The Physician-Director ..... ........ ........... 173
The Physician and the Nurse Practitioner
"Sub-Chief"........ ... ......... .... .......... 176
Gender ..... ......... ...................... ...... 182
Ethnicity ..................... ....... ........... 189
Social Class ............. ............... ....... 197
Summary ...... ..... .............. .... ..... ........ 201
Notes ........................................... 204

VIII CONCLUSION............................ .. ........ 213

Results ......... .............. .. ................ 214
Discussion ........................ ................. 218
Notes .................... ........... .. ........... 225

APPENDICES

A SEMI-STRUCTURED INTERVIEW SCHEDULE.............. 231

B PERCENTAGE OF WORK ACTIVITY FOR TEAM MEMBERS
(FISCAL YEAR 1974-1975) .... ......... ......... 232

BIBLIOGRAPHY ................ ........... ................. 233

BIOGRAPHICAL SKETCH .. ......................... .......... 251


viii
















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

INTERDISCIPLINARY/INTERPROFESSIONAL TEAMWORK:
SOCIO-CULTURAL AND PSYCHOLOGICAL DETERMINANTS
OF TEAM CONFLICT

By

Linda Catherine Illingworth

December 1983

Chairman: Dr. Otto von Mering
Major Department: Anthropology


This dissertation is a qualitative ethnographic case

study of the collaborative difficulties between social sci-

ence and medical personnel in an interdisciplinary/interpro-

fessional health care team, the Children's Health Program

(CHP) team of South City. The study examines these two

groups as distinct subcultures, one consisting of medically

oriented individuals providing medical or psychological

therapy and the other formed by social scientists acting as

researchers. Within this structure, the clinical group

wielded considerably more influence than the researchers,and

the physician dominated the CHP team. The mirror image of

clinical dominance within the team was the secondary or

subsidiary status of social science.











Dissension within the CHP team manifested itself in two

major forms of role conflict. The first occurred when

medical personnel asked the social scientists to assist with

the clinical goals of program funding and psychological

care. The second resulted when medical personnel seemed to

deemphasize research, the area which the social scientists

believed to be their essential contribution. As the domi-

nant group, the clinical staff expected the social sci-

entists to conform to medical expectations.

Personality, gender, ethnicity and social class are

also examined as elements affecting team collaboration. As

factors operating within the context of professional subcul-

tures and medical dominance, they are seen as important but

secondary influences on team operations.

Research on interdisciplinary/interprofessional health

care teams has indicated the commonality of dissension on

such teams. This study confirms that diagnosis but, unlike

previous studies, offers a more comprehensive and thorough

explanation by utilizing the concept of professional subcul-

tures. The dissertation concludes with suggestions for the

recognition and resolution of team conflict.

















CHAPTER I
INTRODUCTION


In recent decades the traditional doctor-nurse team as

the basic model for health care has given way to new types

of health care teams. Spurred by spiralling medical costs

and concern over the quality of health care and by the

desire to improve service delivery, medical personnel began

to create teams composed of a variety of individuals drawn

from different professions or disciplines. Largely in re-

sponse to a demand for increased accountability, there has

also been a trend to include researchers as members of

practicing clinical teams. One result has been the inter-

disciplinary/interprofessional team, an arrangement intended

to enhance the quality of medical care by pulling together

individuals with specialized knowledge of "medical" prob-

lems.

The subject of this study, the Children's Health Pro-

gram (CHP) team of South City, is an example of an inter-

disciplinary/interprofessional team which grew out of this

movement toward more complex team arrangements. As a rela-

tively new phenomenon, the interdisciplinary/interprofes-

sional team has not been the subject of significant social

science research. Despite the strong contemporary interest










in such health care teams, their effectiveness as a method

of health care delivery has yet to be evaluated. The empha-

sis in teamwork literature has been on the creation of

teams, rather than on careful evaluation of their actual

operation. With a few notable exceptions (Berlin 1970; Rae-

Grant and Marcuse 1968), individuals associated with teams

have tended to assume that teams are a superior means of

delivering health care. This has not been confirmed.

Despite the lack of adequate research, teamwork has

been promoted at times with an almost evangelistic fervor,

leading the sociologist Saad Nagi to suggest that teamwork

has become more a matter of "morals" than of strategy

(1975:75). Practitioners expect teams to yield improved

care by offering increased coordination and integration of

services. They have increasingly found themselves in diffi-

cult positions, often faced with complex disease entities

which seem to defy cure. Cardiovascular heart disease and

alcoholism are two examples of fields in which the etiology

and means of treatment are often in dispute. Due to a

vastly increased network of health and social care, more-

over, there is a bewildering array of professionals prepared

to treat one aspect or another of these problems.2 In

response to a situation of enormous complexity, the primary

problem quickly has become one of coordination, and teams

have been hailed as "the" answer.










Promoting teams as the solution to most health care

problems seems premature. Available research suggests that

medical teams are not a panacea for today's health care

needs. The literature on teamwork, for example, is nearly

unanimous in pointing out two serious problems with health

care teams: team conflict and medical dominance. Although

one or both of these is mentioned in almost every work on

teams, it is usually in a somewhat cursory way, and without

any connection necessarily being made between the two.

The widespread reporting of conflict between profes-

sionals within teams indicates strongly that team conflict

is an issue of some concern. If, as a recent study has

suggested, collegiality within teams has a positive effect

on treatment outcome (Feiger and Schmitt 1979), one might

well wonder if the omnipresence of team dissension does not

have a negative impact upon the quality of health care

offered by teams. Although this association was actually

first noted in the 1950s by researchers analyzing staffing

patterns in mental hospitals (Henry 1960; Stanton and

Schwartz 1954), it is surfacing again as a nagging worry for

thoughtful team analysts (see, for example, Furnham, Pendle-

ton and Manicom 1981). Richard Beckhard, for example, has

defined the "effective" team as one in which more time is

devoted to delivering patient care than to fighting over

organizational issues (1972:292).





-4-


The attention accorded medical dominance in team lit-

erature indicates that it is an issue of prime importance.

The term medical dominance refers to the tendency for health

care teams to favor medical concerns and to allow physicians

to automatically assume leadership roles on teams. Ironi-

cally, the ideological support for teams is based on the

assumption that they might help to solve certain medical

problems (for example, the mounting cost and increasing

inaccessibility of medical care) by utilizing "teams" in

which all members are equal participants. The "problem" of

medical dominance, therefore, might be resolved through a

real equality of other participating professionals and dis-

ciplines. It is worthwhile, then, to examine teams to

determine if there is equal participation among team members

and if the team is moving successfully toward the goal of

improved health care.

The problems of team conflict and medical dominance

suggest the importance of examining more closely the value

or operational effectiveness of health care teams. It is

the purpose of this study to do so by providing a detailed

evaluation of one particular team, in this case an interdis-

ciplinary/interprofessional health care team. Since re-

search on health care teams has been limited or inadequate,

I drew a blank when searching team literature for approaches

that might be of use in studying the Children's Health





-5-


Program (CHP) team operations. Choice of methodology for my

examination of collaborative difficulties within teams,

therefore, became an important problem.

I turned to the history of applied research in quest of

possible approaches to the study of team collaboration.

Anthropology's focus on cultures and its resulting concern

with subcultures and subcultural differences offered the

best analytical tool for examining the fit of individual

team members within the culture of the CHP team. A subcul-

tural analysis of the process of teamwork functioning, how-

ever, has not been undertaken previously. By adopting such

a methodological approach, this study provides not only a

unique approach to health care team analysis but also an

evaluation of the problems which have plagued the operation

of health care teams.

The purpose of this chapter is to assess the value of

previous teamwork literature as a means of developing a

detailed explanation of the weaknesses and strengths of

research to date. From this review it will become evident

that a more systematic and in-depth approach to health care

team analysis is essential if the key problems of teamwork

are to be addressed effectively. This chapter also outlines

the basis for my selection of an alternative subcultural

approach. Combining the strengths of previous literature

with my own anthropological orientation, I adopted a






-6-


methodology which seemed to analyze the CHP's interdisci-

plinary/interprofessional health care team.

Chapter II sets forth the circumstances and history of

the CHP team. It is designed to orient the reader to the

fieldwork setting and to indicate the background of the team

both before and immediately after my arrival in South City.

Chapter III provides an in-depth explanation of the choice

of a qualitative methodology, rather than a quantitative

one, and carefully outlines the actual research process

which I followed.

The purpose of Chapter IV is to discuss the conceptu-

alization of two subcultures within the CHP and to document

the presence of medical dominance. One subculture was

formed by members of the social science disciplines and the

other by medical and related clinical professionals. Chap-

ter V explains the necessary and concomitant secondary

status of social science within this arrangement and reveals

the resulting discomfort and low morale of the social scien-

tists. The root of the differences between the two subcul-

tures is the focus of Chapter VI. It focuses on the dif-

ferences in goals and values in an effort to explain the two

critical forms of role conflict which occurred within the

CHP team.

Chapter VII investigates the contribution of personali-

ty, gender, ethnicity and social class to team conflict.











They are treated as independent variables, operating in the

context of subcultural conflict and medical dominance.

Chapter VIII concludes the study by defining the fundamental

issues which emerged between the social science disciplines

and medical professionals as role conflict and role conflict

resolution. It also offers suggestions for overcoming prob-

lems of dissension within teams and for establishing future

research directions.

Review of the Literature on Teamwork

The health care team is a subject which has received

considerable attention from social scientists in recent

decades. Most of the literature, however, has tended to

present the common problem of team conflict without pro-

viding adequate explanation of such conflict. Because of

this insufficient attention to the dynamics of teamwork,

there is no precedent in the literature for an in-depth

analysis of any particular health care team. It is neces-

sary, therefore, to review both teamwork literature and the

history of applied anthropology for helpful clues and ana-

lytical assistance.

The review of the literature examines both general

teamwork and the more specialized interdisciplinary/inter-

professional teams being studied here. Its purpose is to

assess the various approaches that have been utilized by

researchers in an effort to determine the methodology most





-8-


appropriate to studying interdisciplinary/interprofessional

teams. In general, previous research has tended to be

descriptive, rather than analytical, thereby giving a super-

ficial quality to many of the conclusions. The shortcomings

of previous studies, combined with my anthropological orien-

tation, led me to adopt the anthropological construct of

subcultural conflict as a means for analyzing team conflict

in the CHP's interdisciplinary/interprofessional team.

Definition of Teamwork

The use of interdisciplinary teams to provide health

care has grown to almost faddish proportions. One hears the

term "teamwork" brandished everywhere: there are health

teams, interdisciplinary teams, comprehensive health care

teams, medical teams and so on. This rapid increase in the

number and types of team formations has occurred within the

last three decades (Nagi 1975).

Richard Beckhard defines a team as "a group with a

specific task or tasks, the accomplishment of which requires

the interdependent and collaborative efforts of its members"

(1972:292). Other definitions are more specific. A team is

described as "face-to-face interaction" (Nagi 1975:77) be-

tween two or more persons (Rubin, Plovnick and Fry 174:4) in

which a "number of associates all subordinate personal

prominence to the efficiency of the whole" (Webster, as

quoted in Rae-Grant and Marcuse 1968:4). Definitions of the











words "health team" are almost as multitudinous as the teams

themselves. As George Szasz points out, the use of these

words is indiscriminate and may refer to (1) any of those

professionals who belong to the health industry, (2) select

groups of professionals who are working together, or (3)

members of a health care delivery team who employ the

"health team method of health care" (1969:454). In this

study the word team will be used only to refer to a situa-

tion in which more than two collaborators from more than two

professions or disciplines meet in face-to-face interaction

in pursuit of a specific human service or health care goal.

The traditional team within the profession of medicine

has been that of doctor and nurse. A dominant-subordinate

relationship has characterized this arrangement, with the

nurse usually cast in the submissive role (Peeples and

Francis 1968; Wise, Rubin and Beckhard 1974). The highly

structured nature of such relationships, particularly within

surgical teams, has been noted by both Robert Wilson (1966)

and Ruth Coser (1958). This customary assortment of profes-

sions has sometimes been expanded to include social workers

(Burn 1971; Burr 1975; Tanner and Carmichael 1970), profes-

sionals who have also played roles subordinate to that of

the physician.

In contrast, recent developments have changed the very

nature of health teams. Positions have been developed for





-10-


new medical personnel, especially nurse practitioners and

physician's assistants. Areas of social science such as

medical anthropology and medical sociology have been drawn

into, or have made room for themselves in, the field of

health care. Health teams today may be composed of various

combinations of traditional and modern medical and social

science personnel, and at times even include patients. Of

particular interest is the inclusion of social scientists

such as anthropologists (Foster 1974; Hasan 1975; Leighton

1972; Richards 1970) and sociologists (Olesen 1974; Rosen-

gren 1967) as members of medical teams. There has been a

growing concern with the possibility of contributions from

these and other regions of specialization--areas such as the

ministry (Duncombe and Spilircn 1971) and geography (Hunter

1973). A strong, popular interest has developed in the wake

of these team efforts. Proof of this may be found in the

ever-increasing number of semi-popular articles published in

health journals (Frank and Frank 1975; Margolin 1969; Mason

and Parascandola 1972).

The new health care team is thus different in many ways

from the familiar hospital surgical team. Richard Beckhard

(1972) has pointed out some distinctions between these two

teams. Comprehensive health care teams, for example, are

distinguished by discussion and problem solving as a method

of communication, and they will usually find the process of





-11-


decision making to be unclear, their roles to be ambiguous

and their purpose (the delivery of comprehensive health

care) to be general. Surgical teams, on the other hand, are

characterized by one-way commands as a means of communica-

tion and will usually find the procedures of decision making

to be hierarchical, their goals to be clear and their pur-

pose to be specific ("operate" and "close up").

Teamwork has been justified in many ways. Some fre-

quently mentioned explanations are the need for manpower,

the increasing complexity of health problems and the neces-

sity for reorganizing the health system for more efficient

delivery of health care. In Beckhard's estimation, the

issue of manpower is important. He declares teamwork to be

a necessity in needy communities where access to trained

professionals is limited (1972). In such cases team ar-

rangements can allow a doctor, for example, to see only

those patients who are most seriously ill. The problem here

may not be a shortage of physicians but the difficulty of

coordinating the roles of many health professionals (Nagi

1975).

The complex nature of health care concerns has been

cited by many researchers as justification for teamwork.

Health issues have social, cultural, behavioral and biologi-

cal causes (Talbot 1968), and it is felt that the intricate

nature of these and other present-day social problems makes





-12-


the achievement of understanding unlikely if the insights of

other disciplines are not considered (Roose 1969). As John

Hunter remarks: "Like most complex phenomena involving man,

health problems defy compartmentalized thinking and seg-

mented solutions" (1973:2). Irvin Rubin, Mark Plovnick and

Ron Fry argue that teams are a requirement if the goal of

comprehensive health care is to be achieved (1974).

History of Teamwork Literature

Interdisciplinary research teams. The history of con-

temporary teams, emphasizing cooperation and equality be-

tween members, stretches back over four decades. A number

of articles on the formation of interdisciplinary research

teams were published immediately following World War II,

stimulated by the interdisciplinary work occurring during

the war. As a general rule, these articles examined the

negative impact of personality upon team research and the

difficulty of understanding the theoretical constructions

and methodological approaches of other disciplines

(Blackwell 1955; Bronfenbrenner and Devereaux 1952; Caudill

and Roberts 1951; Eaton 1951; Frank 1961; Redlich and Brody

1955; Reusch 1956; Simmons and Davis 1957; Wohl 1955). A

few authors address the particular situation of social sci-

entists conducting research in clinical settings (Goss and

Reader 1956; Mitchell and Mudd 1957; Young 1955), presenting

an overview; yet, others discuss trends within the general





-13-


field of interdisciplinary research (Luszki 1957; Sherif and

Sherif 1969).

Since the 1940s, social psychologists have been inter-

ested in studying group behavior (Zander 1979). The field

of "group studies" developed just prior to World War II and

grew rapidly after the war. It was characteristically in-

fused with the sense of hopeful enthusiasm concerning en-

gineered social change that also typified other applied

social disciplines during that era. In 1947 the National

Training Laboratories were established as a means of

studying group behavior through T-groups, but as time passed

the Laboratories actually appeared to have the effect of

decreasing regard for groups. They were moved to the Uni-

versity of Los Angeles, where they came under the influence

of students of personality theory (rather than social psy-

chologists), and T-groups developed into a form of sensi-

tivity training concerned with increased individual self-

awareness.

As the personal growth industry became big business

during the 1960s and 1970s, there was a corresponding de-

crease of interest in the study of small groups (Goodstein

and Dovico 1979). The resulting "applied group movement"

which is alive and well today is not the same as the study

of groups (Back 1979). Group experience of the former type

provides a source of comfort to individuals seeking a quick





-14-


and inexpensive means of addressing their perception of

personal and social malaise rather than, as was intended in

the original T-groups, a clearer understanding of the pro-

cess of group dynamics.

Interprofessional clinical teams. It is true that both

social scientists, interested in organizing interdiscipli-

nary research, and social psychologists, actively re-

searching small groups, became interested in groups as a

means of effecting organizational goals during the post-

World War II years. To date, however, there seems to have

been virtually no cross-fertilization between these two

areas of inquiry. A similar issue may be raised with ref-

erence to yet another arena developed through the efforts of

mental and physical health professionals: clinical health

and human service interprofessional teams.

These nontraditional clinical teams began to appear in

the late 1950s. They were radically different in organiza-

tion and intent from the traditional doctor-nurse medical

teams. That these teams were numerous is demonstrated in

the review of the literature produced by Rosalie Kane (1975)

and in Monique Tichy's annotated bibliography (1974).

Literature on interprofessional clinical teams falls

into four main categories. The first tends toward popular

"wave of the future" exhortations: "Try it, you'll like it"

(Burn 1971; Burr 1975; Margolin 1969). The second





-15-


introduces descriptions of teamwork problems, usually in

reference to one particular team (Fry and Miller 1974;

Lamberts and Riphagen 1975; Sims and Bauman 1975).

The third category of interprofessional team literature

is made up of brief analyses, usually by sociologists, which

assess the impact of social structure upon role behavior

(Nagi 1975; New 1968). Much of this literature focuses on

roles, thereby highlighting the role confusion often ex-

perienced in interprofessional teams. There is a certain

amount of overlap and duplication between the disciplines

sometimes included in one team, as in the cases of psychia-

trists and psychologists or of physicians and physician's

assistants. Conflict over professional domain is the not

uncommon result (Nagi 1975). Team members may not under-

stand the possibilities offered by another individual's

discipline, and they may have differing or erroneous impres-

sions of each others' expertise, or they may feel threatened

by other team members who share their own area of proficien-

cy.

Decisions about professional domain and assigned re-

sponsibility are difficult to make within teams. Some ana-

lysts feel that job descriptions may prove counter-produc-

tive if they limit the potential for individual growth and

development offered by flexible team organization. Adapta-

bility of roles is often cited as a strong point of teams





-16-


(Beckhard 1972; New 1968; Rubin and Beckhard 1972). These

and similar attitudes can lead, of course, to further role

conflict if team members are unable to agree upon a division

of labor.

General tracts, usually written by or for social

workers who will be working in teams, are the fourth type of

literature on interprofessional clinical teams (Brieland,

Briggs and Leuenberger 1973; Brill 1976; Horwitz 1970; Lam-

bertsen 1969; Rubin, Fry and Plovnick 1978). The best works

in this category are sensitive to some of the factors which

might be influencing team cooperation (Golin and Ducanis

1981); the worst merely provide a laundry list of items.

None of them explains the process of teamwork and none of

them offers a coherent theory of teamwork.

Despite significant differences in quality, this lit-

erature on interprofessional teamwork does concur in raising

the issue of conflict in contemporary health care teams.

Almost every article mentions the difficulty of collabora-

tion. To address these problems, management specialists

began to work with health care teams in the 1960s. It was

at this time that Irwin Rubin, an expert in organizational

development and team building in industry associated with

M.I.T.'s Sloan School of Management, began consultant work

with the Martin Luther King, Jr., Health Center in Bronx,

New York. Rubin applied behavioral science and management






-17-


concepts to the problem of increasing team effectiveness and

came up with the concept of team development, a process in

which teams are helped to process the internal dynamics of

their own group's functioning. His approach concentrates on

internal group behavior, without regard for the larger so-

cio-cultural context within which the team operates. Rubin

and his associates have published a number of reports on

their work (Beckhard 1972; Beckhard 1974; Rubin and Beckhard

1972; Rubin, Fry and Plovnick 1978; Rubin, Plovnick and Fry

1974; Wise et al. 1974; Wise, Rubin and Beckhard 1974).

Interprofessional team literature strongly emphasizes

the notion of joint clinical experience as a prescription

for decreasing "barriers" to teamwork. Those who do not

advocate the use of team development (Kindig 1975) suggest

the employment of T-groups (Odhner 1970; Semrad and Arsenian

1951). Both processes are essentially the same, as both

seek to facilitate learning about group dynamics by team

members. A recent study, however, suggests that the process

of team development does not result in improved team per-

formance, but in a more positive perception by team members

regarding their situation (Woodman and Sherwood 1980).

Others recommend pre-dating group experience for teams

by organizing interprofessional programs of training. The

problem in bringing this about seems to be that medical

students do not respond well to presentations on behavioral





-18-


science theory, feeling it to be "irrelevant and, at best,

trivial" (Volpe 1975:493). When courses for students are

changed to decrease medical bias, students are reportedly

unhappy (Howard and Byl 1971) and resent having their

learning "diluted" (Szasz 1969:466). All such educational

efforts, of course, are based on the assumption that a

change in educational format will lead to a change in stu-

dent attitude. Bonito and Levin point out that such an

assumption may be unwarranted and they recommend investi-

gating such additional factors as socialization, self-selec-

tion and generational effects (1975).

Interdisciplinary/interprofessional teams. Another

type of team came into being in the late 1960s: the inter-

disciplinary/interprofessional team. In such teams social

scientists were charged with the responsibility of re-

searching the program in which clinical professionals were

working (Bennett and Lumsdaine 1975). Development of "Great

Society" social and health programs during those years

stimulated a corresponding demand for evaluation, since both

government and the public wanted assurances that tax dollars

were being spent in the most effective manner. As social

programs multiplied during the 1960s, legislation also

changed to mandate accountability. The field of evaluation

research expanded to meet that demand.





-19-


Most of the literature concerning interprofessional

relationships within interdisciplinary/interprofessional

teams is buried in discussions of evaluation methodology.

Although program evaluators are aware of the determining

influence of "organizationally structured strains" and of

the anxiety engendered by evaluation (Rodman and Kolodny

1971; Skipper, Diers and Leonard 1967; Weiss 1977), they

have no integrated explanatory model on which to base their

discussion of conflict in teamwork.

Additional information on interdisciplinary/interpro-

fessional teams may be found in writings of anthropologists

who discuss the "adjustment" required of academicians moving

into clinical settings. Their ruminations, however, produce

little more than general reports on the discomfort en-

gendered by such moves (Kennedy 1979; Leighton 1972; Ri-

chards 1970; Schensul 1979; Weaver 1968).

In summary, the review of the literature indicates that

various types of teams have been in operation since the

1940s, and that some attention has been given to evaluating

their contribution to American health care. From the inter-

disciplinary research teams of the 1940s and 1950s to the

more modern interprofessional clinical health care teams and

interdisciplinary/interprofessional research-practitioner

teams, the health care team has been applauded as a useful

device for delivering health care. Regardless of the period





-20-


or type of team being examined, the literature usually tends

to be descriptive and prescriptive rather than analytical.

Its most glaring fault is its narrow scope, a weakness which

results from the tendency of social researchers to ignore

the work of their counterparts in other disciplines. The

inadequacy of previous health care team literature was the

basis, in part, for my decision to adopt a new methodologi-

cal approach to the study of the CHP team. Since the ground

broken by earlier social scientists did not bear fruit, I

determined to add important new elements to improve the

yield. The anthropological concept of subcultures, building

upon the best from previous team research, seemed the most

appropriate road to follow.

Applied Anthropological Research

To summarize, anthropology has always distinguished

itself from other disciplines by its focus on culture.

Between the 1920s and the 1940s the earlier "museum-like"

approach to its subject was modified by the addition of

three new elements: the method of participant observation,

increasing opportunities for non-academic work, and de-

creasing availability of isolated cultures traditionally

favored by anthropologists. Applied anthropology was born

of these changes, and its influence was felt in a flurry of

activity during and after World War II. The relative lull





-21-


of the late 1950s and 1960s was ended by renewed activity in

the 1970s and 1980s, particularly as a result of a decrease

in academic employment.

Since World War II, applied anthropology has been sub-

jected to the influence of a fifth element: quantification.

In the form of evaluation research, quantification has tra-

ditionally been the method of choice in agency and institu-

tionally based research.3 Because anthropologists are again

working in these settings, they have had to adopt, or adapt

to, quantitative methodology.

Exposure to quantitative research, and to situations in

which quantitative research is valued, if not demanded, has

had a major impact on the present-day field of applied

anthropology. Michael Angrosino (1976), for example, speaks

of the "new" applied anthropology in reference to the prob-

lem-oriented procedures required in current applied work.

He notes that anthropologists have traditionally been unwil-

ling to "dirty" their hands with administrative or bureau-

cratic responsibilities. There is, however, a limited de-

mand for the traditional qualitative ethnographic contribu-

tions of anthropologists (Agar 1980). Qualitative research

is usually too time consuming to be completed as a part of

short-term contract work. What is needed within the new

multidisciplinary agency framework is "quick and dirty"

survey work. This is not traditional anthropological





-22-


research and some anthropologists have responded by teaching

themselves new research skills. Programs of applied anthro-

pological training have reacted by incorporating training in

quantitative methodology.5

This particular study focuses on the kind of applied

setting in which anthropologists began to work in the 1970s:

an interdisciplinary/interprofessional health care team

which employs anthropologists and other individuals from

diverse disciplines and professions. As a qualitative

study, moreover, it fits squarely within the tradition of

applied medical anthropology research. As an evaluation of

team functioning, it focuses on the organizational structure

of medical care and considers the efficiency of different

forms of health care organization. My own work as an ap-

plied anthropologist-health care team member is a reflection

of the larger change occurring within the discipline and

within United States health care as more anthropologists

become heavily involved in planning, delivering and evalu-

ating health care programs.

The value of applied anthropology is that it offers

both the concept of culture and a qualitative methodology

with which to explore previously unexamined settings.

Having established this, it is also important to review

critically previous team literature for what it might





-23-


contribute to a subcultural analysis of teamwork. It is to

this task that we now turn.

Subcultural Analysis of Teams

While teamwork literature to date does not employ a

subcultural approach in its evaluation of health care team

functioning, it is useful to review the contribution of this

literature to my subcultural analysis. This section begins

with a critique of the "non-subcultural" literature, follows

with a brief assessment of research on medical dominance,

and concludes with a detailed evaluation of the studies

which can be considered as subcultural in some sense.

Critique of Non-Subcultural Analyses of Teams

The review of team literature indicates that previous

research has tended either to produce laundry lists of

factors affecting collaborative teamwork or to address only

one small aspect of the problem. Little attention has been

given to careful definition and categorization of the prob-

lems experienced by teams. The result is a fragmentary,

inconclusive, and confusing body of data. Even commonly

used concepts are often undefined and, as mentioned pre-

viously, there is little cross-referencing between different

areas (see Bronfenbrenner and Devereaux 1952; Golin and

Ducanis 1981; Kane 1975; Nagi 1975). All of these works can

be criticized for lacking an understanding of the dynamics

of the admittedly complex situation of teamwork. Without a





-24-


more focused approach, they cannot explain the process of

team conflict.

Perhaps the most telling criticism to be made of pre-

vious literature is that by ignoring the work of analysts in

other areas, researchers produce work that is too narrow in

scope. If, for example, one focuses only on the variable of

personality, as did some early analysts of interdisciplinary

research teams, the socio-cultural setting of the team is

ignored. While sociologists have studied the impact of

institutional organization upon behavior in medical settings

and social psychologists have examined the role of the

individual within a group and upon group behavior, both can

sometimes be critiqued for emphasizing the importance of

role at the expense of the socio-cultural setting. It is

useless to discuss organization in and of itself without

examining the larger society in which the organization is

set.

The program evaluation literature and the writings of

anthropologists considering the researcher in a clinical

setting are also lacking in scope (see Leighton 1972;

Richards 1970; Rodman and Kolodny 1971; Weiss 1977). Merely

describing problems of adjustment is not sufficient. What

is necessary is explanation of the origin of collaborative

problems. In sum, team literature can be criticized as

disjointed insofar as it covers only one small aspect of the


I





-25-


problem. Previous studies lack an integrated consideration

of all levels of team collaboration, from personality, to

role, to the wider socio-cultural setting in which teams are

shaped.

Treatment of Medical Dominance in Team Literature

Since medical dominance surfaces as an item of concern

in nearly every article and book mentioned in this review,

it merits special attention. Physicians have always been

dominant within health care teams (Freidson 1970a). Because

of their long years of training and the serious nature of

their work, doctors have always been accorded the greatest

amount of responsibility in health care and have been re-

warded with the most status, autonomy, money and power

(Peeples and Francis 1968; Szasz 1969). It should also be

noted that this tendency has been seconded for years by

federal and state statutes regarding licensure and recerti-

fication, malpractice insurance and the legal right to pre-

scribe drugs. It is not surprising, then, that physicians

might expect to make decisions for an entire team.

Present-day teams are often criticized for being physi-

cian-dominated, and thus having a medical bias. Attacking

physicians as cold and removed and therefore incapable of

providing holistic health care (Wise 1975), critics argue

that the physician should not be "the central figure in the

health arena" (Hiatt 1975:263). Indeed, obstacles to





-26-


teamwork are sometimes directly attributed to physicians.

It has been suggested that doctors have a "trained incapa-

city" for change (Geiger 1974:554) and that they resist

changing from entrepreneurial to organizational forms of

medicine (Menke 1971).

Most modern teams strive for collegial relationships

between members. The literature demonstrates that the issue

of equality, however, has not yet been settled. Many an-

alysts argue that all team members must respect each other's

area of competence before teams may operate successfully.

This may require a flexible relationship in which task

determines leadership (Rubin and Beckhard 1972), and it

necessarily implies a kind of equality not traditionally

found in medical settings. Unfortunately, team members are

not always willing to recognize each other's competence (New

1968). As a result, it often falls to marginal disciplines

to demonstrate and win respect for their expertise and

judgment (Richards 1970).

Continuing concern over the issue of medical dominance

is demonstrated by the fear of some sociologists that medi-

cal sociologists have been or will be co-opted by the medi-

cal model. This apprehension is probably a spin-off of

Roth's criticism of sociology as having a management bias,

that is, with being produced in support of medical practi-

tioners rather than of consumers (Johnson 1975). Radical





-27-


sociologists have gone a step further, critiquing the health

care delivery system as an agent of social control (Gouldner

1971; Pflanz 1975).6

Several sociologists have also blamed the paucity of

medical sociological theory on medical domination (Gold

1977; Johnson 1975). In accordance with these changing

perceptions of medicine, David Sims has recommended that

researchers change their focus of investigation from problem

solution to problem definition and has suggested that those

in power have undue influence over the definition of prob-

lems (1979). Traditional hospital settings have been de-

scribed as being "caste-like," with staff members inter-

acting mostly with those of their own occupational group and

with doctors, nurses and ward workers holding three basical-

ly different ideologies concerning the purpose of the hospi-

tal (Wessen 1972). When the rigidly defined groups that

exist within hospitals are different with regard to goals,

communication and role and authority, it is easy to under-

stand the barriers to teamwork which might result.

Critique of Earlier Subcultural Analyses of Teams

While team conflict and medical dominance have been

identified as the key issues in team operation, to date no

coherent analysis of these issues has been forthcoming.

Almost all of the teamwork analysts mentioned earlier in

this chapter discuss the difficulties encountered when





-28-


members of one profession or discipline attempt to work

cooperatively with those of another. They do not, however,

discuss these conflicts in terms of subcultures. Instead,

they blame inadequate preparation for teamwork and point

either to the process of professional socialization or to

the lack of teamwork exposure afforded by traditional

training.

Social science researchers, for example, define prob-

lems of interdisciplinary teamwork as being caused by dis-

ciplinary or professional socialization. Professional so-

cialization is identified as a problem because it develops

professional commitment at the expense of subsequent ability

to interact cooperatively with members of other disciplines

(Frank 1961; Fry and Miller 1974; Geiger 1974; Nagi 1975;

Rodman and Kolodny 1971; Simmons and Davis 1957; Sims and

Bauman 1975; Young 1955). Training, it is argued, deter-

mines perception by specifying the phenomena to be observed

as well as the manner in which observations are conceptu-

alized into a theoretical framework. Education also deter-

mines behavior by prescribing the methods to be used in

studying what one perceives.

In focusing on training, these social scientists

highlight the ethnocentrism of disciplines. Each academic

discipline, they note, is rigidly separated from the next

with little if any overlap. It is an arrangement which






-29-


actually discourages interdisciplinary pursuits (Campbell

1969). Disciplines school students in their own special

languages, and the result is an esoteric jargon for each

profession. Cross-disciplinary communication is a monumen-

tal problem (Horwitz 1969). Individuals who cannot communi-

cate cannot appreciate or respect each other's approach and

have difficulty in developing the common outlook necessary

for joint team efforts.

Additionally, social science investigators note that

traditional disciplinary training provides no model for

cooperative efforts. Instead, disciplines train their mem-

bers to operate in a highly individualistic and competitive

manner as "lone wolves" (Eaton 1951:708). This also dis-

courages collaboration and causes those who do work in teams

to experience problems in keeping their professional identi-

ty while attempting to contribute to team process (Menke

1971; Richards 1970; Szasz 1969). The same difficulty has

been noted in the professions, where physicians who engage

in teamwork move from the entrepreneurial orientation of

private practice into an unfamiliar cooperative setting

(Menke 1971).

Both professions and disciplines also have certain

expectations of their members which may run counter to the

requirements of teamwork. Those who work in academic set-

tings must sometimes revise their expectations of applied





-30-


members in their discipline.7 Team members, in turn, must

often loosen the ties with their discipline because the

stronger these bonds the more difficult the development of

team loyalty. Even traditional ideas of privacy and confi-

dentiality work against the concept of a team (Rubin and

Beckhard 1972). While the doctor-patient relationship is

expected to be "private" and the therapist-client relation-

ship to be "confidential," teamwork necessarily violates

these norms.

Models for egalitarian teamwork are rare in American

society. The precursor of modern teams, the traditional

doctor-nurse team, is not a team at all, but a highly-

structured arrangement between a physician-leader and subor-

dinate nurses, perhaps more akin to the model provided by an

executive and his secretary.8 American sports teams also

offer a non-egalitarian, hierarchical model. The coach runs

the sports team much as a physician directs the traditional

medical team. He tells the players how to perform and what

plays to execute. The coach's plans and set plays are much

like the standing orders a physician might leave with a

nurse practitioner and the players operate within a very

strict, authoritarian framework. Like the doctor, the coach

is referred to by his title: Coach X.

In general, American culture is characterized by its

individualistic orientation. Americans would never call






-31-


themselves collectivistic; rather, they often seem to fear

"collectivism." The strong strain of individualism in Am-

erican society is a powerful inhibitor of collaboration,

evidenced by the fact that Americans tend to resist joining

forces to affect social planning (Dyckman 1969).

Finally, consumers have certain expectations concerning

the packaging of health care which seem to run toward fan-

tasies of a genial, all-knowing, personal physician who

makes housecalls at night--the model of television's "Marcus

Welby." They certainly do not expect treatment by a "team"

of gathered mental and physical health care experts. It is

also possible that consumers, when faced with a team ar-

rangement, expect the physician to be in charge (Peeples and

Francis 1968; Szasz 1969). It has been argued that health

care team members may have similar attitudes, thus forcing

the physician into a position of responsibility he does not

necessarily seek (Pflanz 1975). It may, then, be a reflex

action for team members to "follow the doctor" (Rubin and

Beckhard 1972:327).

Medically oriented analysts of teamwork in health care

settings tend to point to lack of team exposure as the

guilty culprit in producing problems of team collaboration

(Fry and Miller 1974; Jones and Dunn 1974; Kindig 1975;

MacDougall and Elahi 1974; Mason and Parascandola 1972;

Peeples and Francis 1978; Szasz 1969). In contrast to






-32-


social science commentators who point out that training

provides socialization in one narrow area of specialization,

these medically oriented writers focus on what training does

not offer: exposure to other professions through teamwork

experience.

It should be noted that while social scientists are

busy defining the problem as socialization, medically orien-

ted commentators have already moved on to propose exposure

to teamwork as the solution. Each might be criticized: the

social scientists for being unconcerned with the practicali-

ties of problem resolution, the medical scientists for

jumping into solutions before the problem has been fully

defined. This distinction in orientation between medical

and social science personnel will be raised again in Chapter

VI.

The analyses discussed to this point are incomplete

because they do not diagnose the problem of team conflict

with sufficient care. They discuss a process of differen-

tiation between disciplines without naming or discussing the

professional subcultures responsible for generating these

differences. Although several articles mention the dif-

fering "cultures" produced by disciplines and professions

(Nagi 1975; Richards 1970; Rodman and Kolodny 1971; Rubin

and Beckhard 1972; Sims and Bauman 1975; Young 1955), they

do so only in general reference to the fact that team






-33-


members come from different educational backgrounds.9 They

do not discuss the specific impact of professional subcul-

tures on team process. When they focus only upon the way in

which training is structured, they do so at the expense of

understanding training content. In this way they overlook

the formation of subcultures and their impact on the be-

havior and attitude of individuals engaged in teamwork.

Some studies adopt a more explicitly subcultural orien-

tation, and are, therefore, more valuable contributions to

our understanding of team functioning. Although he does not

directly address the issue of teamwork, C.P. Snow offers

useful information on subcultural differences between dis-

ciplines and professions. In his classic work, The Two

Cultures and the Scientific Revolution (1961), he describes

the existence of two totally different and mutually exclu-

sive cultures in Western civilization:

[the] literary intellectuals [are] at one pole--at
the other scientists .. Between the two a
gulf of mutual incomprehension--sometimes (par-
ticularly among the young) hostility and dislike,
but most of all lack of understanding. (1961:4)

Snow notes that members of each culture can easily under-

stand one another: "Without thinking about it, they respond

alike. That is what culture means" (1961:11). They cannot,

however, understand individuals of the other culture. Be-

cause they cannot talk to each other, each lacks knowledge






-34-


of and respect for the goals and achievements of the other

culture.

George Foster takes this type of cultural analysis one

step further in his discussion of cultural distinctions

between disciplines and professions (1962, 1969). In re-

viewing problems of cooperation encountered by administra-

tors and anthropologists working together in action research

settings, he refers to a subculturall chasm" between the two

groups. Foster believes this gap to be directly related to

differences in values, methods and goals between the admin-

istrators, who are drawn from professional schools of

training, and anthropologists, who have received discipli-

nary training. He briefly discusses the influence of disci-

plinary and professional affiliation upon the process of

team collaboration. Anthropologists, for example, are

perceived by Foster as valuing knowledge and pursuing the-

oretical research as a goal. Administrators, on the other

hand, are held to prize the achievement of organizational

goals and to seek problem-solving action as a goal. In

making such a firm distinction between research and action,

Foster tends to exaggerate, probably for the purpose of

analysis. Nevertheless, it is a useful distinction which

offers a framework for examining the subtleties of subcul-

tures in more detail. The difference between the medically-

oriented professionals and the social scientists with





-35-


disciplinary affiliation is of major importance within the

CHP team and will be examined in depth in Chapter VI.

David Banta and Renee Fox (1972) have produced a useful

study on the professional functioning of the health care

teams formed in the first Office of Economic Opportunity

Health Center in Columbia Point in Boston. They interviewed

the physicians, social workers and public health nurses who

were members of these health care teams. Analyzing differ-

ences in values and goals among professional groups, envi-

ronmental and institutional stresses experienced by staff

and methods used for coping with stress, they concluded with

a discussion of the manner in which each group viewed the

professional functioning of their own and of other groups.

Although the article is quite useful in providing an

idea of the strains experienced by professionals attempting

cooperative teamwork, it does not adequately address the

process of team conflict. The authors discuss the problem of

role definition but do not adequately explain the source of

the "multiple group tensions" experienced by team members.

Furthermore, while they note that the teams were intended to

be egalitarian, that physicians tended to assume team

leadership in spite of this, and that there was a lack of

peer relationships within the teams, they make these obser-

vations in a cursory and disconnected manner. The result is






-36-


a provocative but confusing article which does not ade-

quately explain the process of team conflict.

Adrian Furnham, David Pendleton and Charles Manicom

(1981) also discuss the perception of different occupations

within the medical profession. Under the assumption that

members of different occupational groups perceive each other

in characteristically different ways, they tested the hypo-

thesis that those groups who perceived their traditional

field of knowledge, style of operation, or client groups as

being appropriated by yet another group would appraise that

second or out-group unsympathetically. By asking 125 pro-

fessionals in medical and allied health services (nurses,

occupational therapists, health visitors, doctors and social

workers) to rate twelve professions, they found this to be

true and concluded that separation into occupational groups

appears to trigger the psychological mechanism of intergroup

prejudice. Their work provides a very useful orientation by

linking the psychological reaction of team members to group

affiliation. They do not, however, discuss the particular

impact of these stereotypes in affecting role performance on

a working team and in inhibiting the process of day-to-day

collaboration. What is needed is a more in-depth study of

the source, nature and consequences of the stereotypical and

prejudicial perceptions of one profession by another. In

the case of the CHP team, we must also consider the addition





-37-


of academic disciplines to the more traditional medical and

allied health professions.

June Huntington (1981) also deals with small groups in

dissecting "inter-occupational differences" between social

workers and general practitioners involved in collaborative

efforts. Although she does not specifically refer to this

organizational arrangement as teamwork, the two occupations

do interact in a teamwork situation. Huntington lists ten

"cultural" and eight "structural" variables which she main-

tains affect inter-occupational relationships. She notes

that differences in time orientation relate to three of

these eighteen variables and function to inhibit collabora-

tion.

Her article is useful in that it thoroughly documents

the existence of occupational differences and demonstrates

awareness of "cross-cultural differences" (1981:208). Her

conclusions with regard to time orientation support my own.

Less useful is her theoretical framework. She presents a

shopping list of social and cultural factors without indi-

cating their relative importance or the relationship among

them. She needlessly complicates the analysis of "conflic-

tual rather than collaborative" relationships (1981:208).

My inquiry into the CHP team attempts to analyze the problem

of team collaboration through a less complex but more






-38-


focused treatment of subcultures which may form within a

team and which may be composed of one or more occupations.

A final useful approach to team analysis has been

produced by those who consider teams as small groups. In

his book, The Sociology of Small Groups (1967), Theodore

Mills, for example, discusses small groups from the vantage

point of a newcomer moving through certain stages in coming

to accept a group as his own. In highlighting the induction

of new members into small groups, Mills focuses on the

juncture between individual/emotional experience and group

experience. Although he stresses the importance of socio-

cultural context, he does not explore it; instead, he pre-

fers to focus on the individual.10

Because of its emphasis on the fit between individual

and group behavior, Mills' analysis provides an excellent

means of understanding the induction of an individual into a

relatively cohesive group. In dealing with team conflict,

however, we are not dealing with homogeneous groups. In

interdisciplinary/interprofessional teams, we have situa-

tions in which disparate groups are forced into cooperation.

Team situations involve a predictable amount of disharmony.

It is more analytically powerful to approach the problem of

discord by examining the juncture between the group and the

larger socio-cultural setting from which its members are

drawn than to look at the joining of the individual and the





-39-


group. This brings us to a focus on culture, or more spe-

cifically, to a focus on subcultures which form within

teams.

Summary

Despite the growth of interest in teamwork, team con-

flict and medical dominance have been serious obstacles to

effective collaboration in modern health care teams. Unlike

the traditional hierarchical doctor-nurse team, modern in-

terdisciplinary research teams, interprofessional clinical

teams and interdisciplinary/interprofessional teams expect

collaborative work relationships as an integral part of

providing comprehensive services to consumers. Such col-

laboration does not appear to be forthcoming.

Research on such teams to date reveals collaborative

difficulties but tends to be too narrowly focused. Investi-

gations of interdisciplinary research teams, for example,

concentrate on the negative impact of personality and empha-

size the difficulty team members experience in attempting to

understand methodological and theoretical differentiation

between disciplines. In contrast, examinations of clinical

health and human service interprofessional teams tends to be

of four types: (1) "try it, you'll like it" exhortations,

(2) descriptions of particular teams, (3) brief sociological

analyses focusing on roles and (4) general tracts written

for or by social workers who will be working on teams.





-40-


Finally, research on interdisciplinary/interprofessional

teams highlights problems of adjustment experienced by aca-

demic researchers as they move into clinical work settings.

In each case these discussions tend to ignore the work of

researchers in other teams and tend to fail to offer a

coherent theory of teamwork. What is lacking is an inte-

grated consideration of all levels of team collaboration,

from personality, to role, to the larger socio-cultural

setting.

In developing the methodology of this study, I criti-

cally reviewed previous team literature. It was evident

that no ethnographic study of teamwork existed and that the

literature often tended to be contradictory. To overcome

the methodological weaknesses of teamwork literature, I

carefully reviewed applied anthropological research in

search of an approach which would provide more accurate

results. I adopted a subcultural and qualitative methodolo-

gy because of its advantages in this particular research

setting. By examining the fit of individual team members

within the socio-cultural setting of the Children's Health

Program team, this study provides a unique approach to

health care team analysis as well as an evaluation of the

problems of team conflict and medical dominance which have

plagued the operations of health care teams.


I





-41-


My basic criticism of teamwork literature is that it

bypasses subcultural analysis of teams in favor of blaming

conflict either on disciplinary training or on the lack of

opportunity for joint educational experiences between mem-

bers of different professions. Too often, team analysts

have focused on the manner in which training is structured

at the expense of understanding the content of that

training. As a result, they overlook the significance of

subcultures and their impact upon the process of teamwork.

A few researchers do attempt a more specifically sub-

cultural analysis of team conflict, but either do not pursue

this issue in sufficient depth or needlessly complicate the

question. C.P. Snow (1961) and George Foster (1962, 1969),

for example, discuss subcultural differences between disci-

plines and professions but do not elaborate sufficiently to

allow a dynamic understanding of this process. David Banta

and Renee Fox (1972) discuss the "strains" inherent in

cooperative teamwork but confuse the structural concept of

role definition as an explanation for the process of team

conflict rather than viewing it as a symptom of underlying

problems of subcultural conflict. Other researchers also

fail either to offer a comprehensive vision of team conflict

(Furnham, Pendleton and Manicom 1981; Mills 1967) or compli-

cate our understanding of team conflict by listing too many

influencing factors which are not integrated in a





-42-


comprehensive and understandable manner (Huntington 1981).

In spite of these shortcomings, team literature does provide

a foundation upon which to build. By combining the

strengths of the previous literature with my own anthropolo-

gical orientation, I was able to adopt a methodology well

suited to analysis of the CHP's interdisciplinary/interpro-

fessional health care team.

To date, there has been no sufficiently holistic study

of the problem of teamwork and teamwork functioning. This

study, by focusing on the relations between professionals in

one particular interdisciplinary/interprofessional health

care team, the Children's Health Program team, attempts to

remedy this lack. It demonstrates how the concept of two

subcultures helps to make observations of teamwork more

understandable. The minute examinations provided by a case

study of the day-to-day functioning of one team make it

possible to understand the roots and process of team con-

flict, the oft-mentioned but never-explained obstacle to

teamwork.



Notes

1. The names of the city, the physician and all other parti-
cipants have been changed in order to protect confiden-
tiality.

2. While there were only sixty health professionals trained
in other fields for each one hundred physicians in 1900,
by 1960 there were 371 (Cohen 1971).





-43-


3. Traditional evaluation research emphasizes quantitative
analysis, to the exclusion of qualitative approaches, in
measuring the achievement of program goals. The classic
Fisherian experimental design is held as the research
ideal (Houston 1972). Evaluation research involves the
use of experimental research design, when an experimental
and control group are randomly selected. The experimen-
tal group is subjected to treatment while the control
group receives no treatment, and variability between the
two groups is then estimated. Many program evaluators
consider experimental research to provide the most power-
ful means of testing social action programs (Rossi 1972).
In what have been called the "bibles" of evaluation
research, Donald Campbell and Julian Stanley (1966) and
T.C. Cook and Donald Campbell (1975), in a revised ver-
sion of the same material, compare all research designs
unfavorably to randomized controlled experiments.

4. Many general books deal with problems of conceptualizing
and executing evaluation research. See, for example,
John Heilman (1977); Herbert Hyman and Charles Wright
(1971); Peter Rossi, Howard Freeman and Sonia Wright
(1979); and Carol Weiss (1972). These books are written
by program evaluators who outline and suggest means of
overcoming the problems inherent in quantitative program
evaluation. They do not suggest qualitative approaches
as an alternative.

5. Anthropologists have traditionally had little exposure to
or training in quantification. Anne Roe, in discussing
the differences between anthropologists, psychologists,
biological and physical scientists, noted that of the
four, anthropologists held both the least interest and
lowest ability in mathematics (1952, 1953).

6. P.M. Strong counter-attacks by accusing sociologists of
producing "exaggerated" reports of medical dominance
(1979:200) because of their own imperialist ambitions.
He points out that a social model of health would provide

an even better vehicle of oppression than that already
offered by organic medicine.

7. For example, applied work often does not leave sufficient
time for research and publishing, the two areas which
academics evaluating each other often judge as most im-
portant.






-44-


8. The absolute fear by some physicians of sharing this
traditional power is revealed in the attack of a physi-
cian-psychiatrist upon those physicians who engage in
egalitarian teamwork. He accuses his colleagues of
giving sway to their "passive defenses and feminine iden-
tifications" (Berlin 1970:147).

9. Of these, Young makes the strongest case for analyzing
"subcultures," stating that such an approach is "the key"
to success in teamwork (1955:647). His comments, how-
ever, remain general.

10. Mills identifies a major advance produced by small group
studies as being the reduction of "the trichotomy between
the individual, the group, and society" (1967:9). The
individual is now viewed as being both "in the group and
of society" (1967:9). He refers to "group culture" in
discussing a group's beliefs and values, defining it as
"the set of shared (explicit and implicit) definitions of
reality; preferences among objects, ideas, and states of
affairs; and standard procedures for pursuing the desira-
ble--all as collectively defined" (1967:95). He does
not, however, discuss group culture in detail.

















CHAPTER II
TEAM HISTORY AND FIELDWORK SETTING


My memories of the town of South City are idyllic:

early morning light, green lawns, the sharp freshness of a

high blue sky, moist sea air breezing gently through the day

and lights, soft twinkling lights, rimming the bay on which

South City perched and a sprinkling of yet more lights under

the high arching causeway on which motorists entered the

city. These tranquil, peaceful images could not contrast

more sharply with the stressful, anxious days I spent as a

staff member on the CHP team. Dissension was rife on this

team, manifested most strongly in the open expression of

hostility between team members. As startled as I was to

discover a team filled with strife, a review of team litera-

ture persuaded me that the CHP team was not an exception.

As the review of the literature in the previous chapter

indicates, collaborative problems in teams are more the norm

than the exception. Given the fact that the "team ap-

proach," particularly one utilizing both social science and

medical personnel, is innovative, problems of cooperation

within the CHP team could have been predicted from the

first. During my tenure with the CHP, from October, 1974,

until July, 1976, the creation of a collaborative team


-45-





-46-


relationship proved elusive.1 The intent of the program was

to provide an interdisciplinary approach to health care

through teamwork. The outcome was a team in which the

medical members busied themselves with clinical work and the

social scientists restricted themselves largely to research.

The two groups remained segregated. There was much friction

between team members and although the situation changed

somewhat as communication improved, the experience was a

difficult one for those involved.

This chapter orients the reader to the subject of this

study: an operating, interdisciplinary/interprofessional

team. It includes an outline of the team's historical

background, a brief description of the fieldwork setting

between the research years from 1974 until 1976, and an

assessment of the effect of the first anthropologist's

presence prior to 1974. The chapter concludes with a dis-

cussion of the reception subsequently afforded the first

anthropologist's "replacements," the second anthropologist

(LCI) and the sociologist.

CHP Team History

The CHP team received its first funding in September of

1972. Before that date it had existed only as the dream-

child of Dr. X. Practicing as a South City pediatrician,

Dr. X was bored with general practice, uncertain of how to

handle the "behavioral problems" he encountered in his


I





-47-


patients, and generally lacking in what he called "self

satisfaction." He left South City to undergo additional

training as a subspecialist in pediatric cardiology, re-

turning in 1967 as Director of the Department of Cardiology

in the Children's Hospital.

Dr. X, however, felt "lonely" in South City and com-

plained that the area was "intellectually dead." More

serious was the fact that the population density of South

City was not high enough to support his practice as a pedi-

atric cardiologist. In 1968 he began to travel to the

outlying areas of South City, known locally as "the Basin,"

in order to secure patients. Dr. X was accompanied by the

hospital EKG technician who was later to function as the

"technician-administrator" of the CHP team.

His difficulty in maintaining a practice caused Dr. X

to become interested in large-scale screening programs which

would funnel children with congenital heart disease into his

practice. In 1969 he applied for local funding to support

such a screening project but was turned down. During the

process of application, Dr. X developed the idea of training

nurses for an expanded role in providing health care. In-

trigued with this new notion, he saw the use of such nurses,

who would also be Mexican American, as a possible solution

to the "cultural problems" he found himself facing in the

Basin with his now largely Mexican American clientele.





-48-


Beyond problems of communication with non-English speakers,

the issue of specific concern was patient compliance: "Why

people wouldn't take my advice about medical management."2

Dr. X had also become aware of "the complete insensitivity

within the hospital to the cultural needs of the patient."

Children's Hospital employees, for example, were not allowed

to speak Spanish to patients of Dr. X who had been hospi-

talized for catheterization or open heart surgery.

During this same time period, Dr. X met a medical

anthropologist. Coming to believe that "others besides the

physician were important," he was "excited" by the prospect

of including an anthropologist as "someone who could under-

stand people." Dr. X believed medicine to be too biomedi-

cally oriented and was interested in increased interchange

between the medical and social sciences. "In medicine," he

once commented, "we've left out a great deal of man's be-

havior." Dr. X was also exposed to representatives of the

local mental health center and was "talked into" adding a

psychiatric social worker to his grant request. He noted:

"I had no idea what the psychiatric social worker would do

other than shed some light on different cultures. I guess I

picked the anthropologist already knowing what he would do."

In 1972 Dr. X submitted a new grant application con-

taining staff positions for himself, the "EKG technician-

administrator," expanded-role nurses, an anthropologist, and





-49-


a psychiatric social worker. This proposal was funded by a

Regional Medical Program grant of locally-disbursed federal

money. Between the months of October, 1972, and January,

1973, he hired the new staff members. Although the grant

stipulated that master's level Mexican American nurses be

hired for training in pediatric cardiology, none was availa-

ble. Instead, Dr. X secured three Mexican American nurses

with diploma or Associate of Arts degrees. Between 1972 and

1974 two of the original three nurses, both female, re-

signed, leaving behind one male nurse. Two new male Mexican

American nurses were then recruited and trained.

Although the original grant had been awarded for a

three year period, the program lost this funding within its

first months of operation as a result of federal budget

cuts. The program then found it necessary to seek funding

on a yearly basis, first receiving Organization for Economic

Opportunity (OEO) funding and later funding from private

foundations and federal and state agencies.

In addition to these unexpected problems with funding,

Dr. X encountered further difficulties in directing grant

administration and managing program staff: "I couldn't

watch over everybody; I didn't have enough time." A secre-

tarial position ("secretary-coordinator") was added in 1973

to help in this regard.





-50-


The program was only sporadically staffed prior to 1974

by a psychiatric social worker in several part-time and

full-time arrangements. The first anthropologist was hired

in November, 1972, and remained with the program until the

summer of 1974. A newly graduated Ph.D., this Anglo anthro-

pologist was from the Northeast and had several years of

living and fieldwork experience in Mexico. In addition to

providing a new social science perspective to the solution

of medical problems, the first anthropologist taught the

physician about the cultural background of his Mexican Am-

erican clients, particularly as related to their beliefs and

actions as medical patients. As the physician's wife noted:

The first anthropologist educated Dr. X in what
the Mexican American was like. He learned a
great deal from the first anthropologist that the
nurse practitioners wouldn't know to tell him.
The first anthropologist was a student of this
sort of thing and he taught Dr. X how to relate
to the Mexican American patients.

The position of economist was added to the team in 1974

after the program was criticized by a local grant review

board as "inefficient."

Field Setting

When the research for this study was first begun in

October of 1974,3 twelve full-time and part-time staff mem-

bers from the medical professions and social science disci-

plines made up the CHP team. The full-time team members,

listed in the general order of their entry into the program,






-51-


included the "director" of the program, a pediatric cardi-

ologist, also Director of the Cardiology Department of the

Children's Hospital; a technician-administrator, also chief

of the EKG-EEG staff at Children's Hospital; four Mexican

American nurses, certified as nurse practitioners and "pe-

diatric cardiology associates," the newest of whom and only

female was still in training; a secretary-coordinator; a

social worker; a sociologist; and an anthropologist. The

team also employed two part-time members, an economist and a

"public relations consultant.

Of all the team members, the social scientists were the

newest. The economist had begun his association with the

program during the previous spring. He lived in a large

city, 200 miles distant, and commuted to South City once a

week. The second anthropologist was new not only to the CHP

but also to the community, having just moved to South City

to take the CHP position as program anthropologist. The

sociologist was a native of South City. He had been em-

ployed for roughly one month before the anthropologist ar-

rived, had quit citing a chronic health condition as the

reason, and, after being absent for several weeks, had

renegotiated his employment with the CHP. The male, Mexican

American social worker was from a large city north of South

City. In order to work with the CHP team, he had moved to






-52-


the community of South City several weeks before the arrival

of the anthropologist.

The physician, founder and director of the team, was a

subspecialist in pediatric cardiology. As there was virtu-

ally no rheumatic heart disease in that area of the

Southwest, the physician was concerned with diagnosing and

treating congenital heart disease.5 The physician was

trained to perform cardiac catheterization, a diagnostic

procedure in which the chambers of the heart are probed with

a catheter inserted in the femoral artery. Pediatric car-

diologists do not perform corrective surgery but are, how-

ever, responsible for continuing care after surgery.

The nurses assisted the physician in his efforts to

diagnose and treat heart disease. These nurses received

eight months of training from Dr. X in various aspects of

pediatric cardiology and child health care. They took an

additional four months of training in a nurse practitioner

program located at a university 230 miles from South City.

In their expanded roles, the nurse practitioners met

with the patients prior to Dr. X. They gave physical exam-

inations and took medical and social histories. Combining

this information with their interpretations of EKG, X-Ray

and laboratory tests, they produced a preliminary diagnosis

attempting to "detect and interpret heart murmurs." Their





-53-


work was considered to be "under the supervision of the

physician" and, when completed, was reviewed by him.

Dr. X was responsible for diagnosing the patient and

organizing plans for patient management. The nurse practi-

tioners were the ones to carry out these plans, explaining

medical actions to the patient and his or her family. The

rationale behind this arrangement was, in the words of the

physician: (1) "the nurse practitioners will carry our ser-

vices to a larger number of needy children," and (2) "this

arrangement permits the physician to allocate his time more

efficiently."

The technician-administrator performed necessary medi-

cal tests such as EKG-EEG, ear oximetry and vector-echocar-

diogram. She was also responsible for bookkeeping and other

clerical-administrative functions. The secretary-coordina-

tor was charged with ensuring intra-team coordination in

addition to her secretarial work. Social and emotional care

not provided by the physician or nurse practitioners was

offered by the social worker. The anthropologist and soci-

ologist were to research program/health concerns and to

teach social science to medical personnel. The public rela-

tions consultant raised program funds and the economist

oversaw the program's fiscal management. These descrip-

tions are simplified and obviously overlapping--an issue

which will be dealt with at further length in Chapter VI.





-54-


It was the goal of the CHP to provide multidisciplinary

health care by diagnosing and treating children with con-

genital heart disease. The program's clientele was drawn

from an impoverished area of the country where 40.7 percent

of all families fell below federally established poverty

lines. Of those patients seen by the CHP team, 86 percent

were Mexican American, 11 percent Anglo, and 3 percent

black. The median income of these families fell between

$200 and $300 per month.

This largely indigent, Mexican American population was

spread over an area of 24,000 square miles. Operating from

a South City base, the team covered this 22-county area, the

Basin, with a system of 11 satellite clinics,7 each of which

was visited monthly or bi-monthly. Patients requiring com-

plex diagnostic procedures, intensive care or surgery were

referred to the Children's Hospital in South City for fur-

ther diagnosis and treatment.

A 90-bed pediatric hospital, the Children's Hospital

was founded in the 1950s as a charity institution intended

to provide hospital and outpatient care for indigent

children in a 39-county area surrounding South City. When

this study began in 1974, the hospital had become a not-for-

profit operation. The hospital offered the only pediatric

subspecialty care in the region and housed the offices of

the CHP team.





-55-


Within the Children's Hospital the nurse practitioners

made daily ward rounds of all in-hospital patients, acting

as "physician-delegates." In doing so, they monitored pa-

tients, explained treatment and solved "non-medical" prob-

lems. They carried out plans which had been formulated and

delegated to them in the daily patient management meetings.

The nurse practitioners also saw patients during the thrice

weekly outpatient screening sessions held in both the South

City Children's Hospital and the Basin, trained public

health nurses to do screening for heart murmurs and taught

hospital residents about cardiology.

One of the three nurse practitioners was stationed in a

town in the Basin and the nurse practitioner in training was

slated for similar outpost duty in another town. Working

through the local public health department, these nurse

practitioners were to screen and perform a preliminary

evaluation of clients with suspected heart murmurs who

would then be "reappointed for final medical diagnosis."

They also provided follow-up for known cases.

The First Anthropologist

In the fall of 1974, the early days of the sociologist

and second anthropologist were punctuated by constant ref-

erence to the unacceptable ways of "your predecessor." The

first program anthropologist was cited as not having been





-56-


"accepted by hardly anybody."10 As one medical professional

complained with feeling:

We all felt like an individual with a lot of
education came in and kind of put us down and he
was a person we didn't see utilizing his time
efficiently or really doing anything. I think we
all perceived social scientists as people who
came aboard and sat around talking instead of
doing.

There was some awareness within the program of the problems

of role definition which the first anthropologist might have

encountered in attempting to define a place for himself on

the team. Dr. X was particularly sensitive to this issue:

I really wanted the first anthropologist to find
out what his role was. I didn't know! He was
only the second anthropologist I ever met. I
didn't know anything about anthropology, couldn't
have written a job description if I'd wanted to.
I can understand how the first anthropologist
might have felt confused about the same thing.

The more usual reaction within the team was for the

first anthropologist to be regarded as responsible for his

own lack of acceptance. His status as an anthropologist

then produced an additional sore point. As a medical team

member declared:

I originally thought an anthropologist must be
someone who could go out and live with the na-
tives: eat out of the same plates, sleep on the
same bed, get their hands dirty and be accepted.
With the first anthropologist, we were involved
with an individual who just couldn't do that in
this setting, who just couldn't get his hands
dirty. It was kind of a let-down when you expect
an anthropologist of all people to be able to
adapt to the culture of the team.





-57-


More specifically, the first anthropologist was also

criticized by the nurse practitioners for his interactions

with the hospital power elite:

He ended up hanging around with just the big
wheels in the hospital. He didn't want to hang
around the low people. He stated he wanted to
work with "the people" and turned around and did
the opposite.

The first anthropologist was familiar with these complaints

and refuted them:

They thought that I was somehow feathering my own
nest and that I was trying to build a power base.
They never questioned their own assumptions be-
cause that's what they would have done if they
had been in my position.

Another area of difficulty was posed by the first

anthropologist's vocabulary. Early in her stay with the

CHP, the physician gave the second anthropologist a letter

written by the first anthropologist and requested a

"translation." He complained: "I have a hard time under-

standing what he writes. I've often been unable, after

talking to him, to say just what exactly we did talk about."

Even the second anthropologist had some difficulty working

through this letter, but with diligent application was able

to produce a translation into plain English. The physician

remained distressed by the first anthropologist's use of

words:

It was just verbiage, anomalous verbiage. You
don't know what all that stuff means; you just
sit there and it inundates you. To what purpose?





-58-


He's not teaching me anything. It just drowns
me. I can't even follow it to question it.

In such instances one might conjecture that words had

become the first anthropologist's instrument of reprisal.

In a setting in which he perceived no support, he may have

honed words into the weapon of verbiage. It was perhaps a

pleasant form of revenge, as it obviously left medical

personnel reeling in its wake. All of this, however, did

not change the medical view of the first anthropologist as

"someone who came on board and sat around talking instead of

doing." This interpretation is suggested by the first an-

thropologist's response when informed that the physician was

having difficulty understanding him:

He wants to be spoon-fed. If he doesn't like it,
that's too bad. That's the way I give it. If he
wants to get into the big time, he'll have to
improve his vocabulary.

In all of this, of course, the first anthropologist armed

his fellow team members with a verbal axe handle to use on

his successors.

The "New" Social Scientists

Because of "difficulties" they encountered in dealing

with the first anthropologist, medical team members assumed

the situation would be identical with all social scientists.

The following quotation from a nurse practitioner summarizes

the worst of the sentiment against the social scientists:






-59-


The person that sponsored you was not very well
received here. As long as the social scientists
come sponsored solely by that individual, and in
your case he was the chief locator, coordinator
and expressor [sic] of how it was going to be,
then it's a tragedy. The first anthropologist had
so many problems that anybody he selected had to
have some problems of their [sic] own, something
wrong with them [sic] too, to make the first
anthropologist say: "You're a good person for the
team."

Or, as another nurse practitioner noted sympathetically:

When you first came here you came in someone
else's shoes. You were already judged and sen-
tenced before you even got started.

The first anthropologist was also aware of this hostility

and stated apologetically: "I pre-socialized [sic] the

medical personnel against you."

Reactions of distrust and dislike expressed toward the

first anthropologist were thus visited again on the new

social scientists. Team members were aware of this process:

Problems when you first came were our fault be-
cause we didn't accept you like we should have.
I guess we were upset because the first anthro-
pologist would come in whenever he damn well
pleased and leave when he wanted to. You never
knew when he was going to be here or if you could
depend on him. I guess all of us were skeptical
wondering if this was going to start up all over
again with you. I thought: "I hope it's not
another first anthropologist." You know that
wasn't fair.

As the previous quotations indicate, the sociologist and

second anthropologist were accorded a frosty reception.

This strained atmosphere was relieved on occasion by the

periodic supportive interventions which the project





-60-


director, Dr. X, made on behalf of the social scientists.

As the team member who initially conceived of using social

scientists as members of the medical team, he was their most

enthusiastic proponent. On the whole, however, the recep-

tion and treatment of the social scientists during their

initial months with the CHP was cool indeed. A medical team

member later noted:

When you first came, very few people would even
talk to you. To tell the truth, we don't welcome
new people with open arms around here. We seem
to want them to prove themselves before we accept
them and we don't go out of our way to help them
either.12

In a similar vein, another team member explained this situa-

tion to a program outsider: "The social scientists didn't

know what to expect. They walked into a bad situation on

eggshells."

An already difficult situation was then complicated by

the social scientists' response. They marshalled their

joint forces by banding together. Spending much of their

time in their office, they attempted to figure out what was

happening and to discover its cause. This gave team members

further reason for alarm: "I got the feeling at first that

you two were getting together and yakkity yakking, saying

'Just to heck with that bunch, we're going to do our own

thing.'" As another noted: "You people can't do that

because you're setting up a new power structure. You should

know no one will stand for that." In addition, feelings of





-61-


anxiety inhibited interpersonal communication between the

anthropologist and sociologist and their fellow team mem-

bers. As a team member later commented: "The sociologist

came on strong and it drove them off and the anthropologist

was very shy and they didn't know how to approach her."13

The social scientists were in a self-described "state

of shock" at their reception by the CHP team. The sociolo-

gist saw the team setting as "very hostile." The anthro-

pologist concurred, further stating: "I can't believe this.

If this is applied anthropology, I'm going to change

fields." The economist criticized other team members for

not accepting the anthropologist and sociologist, pointing

out the negative effect on team productivity:

I think we can expect that people who are made to
feel welcome will perform better. If it's per-
formance we're after, I think it behooves us to
treat people well when they come into this team.
If people feel interpersonally insecure, there's
no way they're going to be innovative. I think
we lost about three months of productivity out of
the sociologist and second anthropologist during
their initial time with us. If they'd been made
to feel more welcome, things would have gone much
more smoothly.

Summary

The historical background of the CHP prior to 1974

reveals a heritage of "bad will" which often bordered on

outright hostility. Initially unaware of the full extent of

the negative legacy of the first anthropologist and of the

confusion among medical personnel, the new social scientists





-62-


found it necessary to adapt to a difficult situation. Even

though they eventually embarked on a concerted effort to

"make themselves useful" and thus to increase their level of

acceptance, problems of teamwork continued. The difficulty,

as will be made clear, was not merely one of personal accep-

tance; rather, it was one of fundamental conflict between

the medical and social science approach to health care.


Notes

1. Although this research on the difficulties of team colla-
boration was completed between 1974 and 1976, the problem
of interprofessional rivalry and tension is in no way
dated now, in 1983. As Warren Kinston points out in a
recent article on interprofessional behavior in hospital
settings, "the struggle for status amongst the profes-
sions and semi-professions is now a regular part of
health politics" (1983:1160). He concludes: "There is
considerable friction within most professions and between
almost any professional groups that come into contact"
(1983:1162). Contemporary collaborative problems are
also discussed by Huntington (1981) and Miller & Rehr
(1983) in reference to the professions of medicine and
social work and by Chrisman and Maretzki (1982) and
Kleinman (1982) in reference to health sciences and an-
thropology.

2. Patient non-compliance with medical directions is appar-
ently a common phenomenon. Mary-'Vesta Marston notes a
wide range (from 4 percent to 100 percent) in compliance
reported in published reports. She also references M.S.
Davis' review of the literature and subsequent estimate
that approximately 30 to 35 percent of patients do not
follow their doctor's recommendations (1970).

3. I collected the data for this study while employed with
the CHP first as a full-time medical anthropologist-team
member for nine months from October, 1974, until July,
1975, and then as a consultant (I made monthly return
visits of three to five days each from my home base in
Mexico City) for the subsequent year from August, 1975,
until July, 1976.





-63-


4. Some hospital staff members were also associated with the
program: EKG technicians, Dr. X's wife, who was in
charge of financial billings, and an insurance clerk.
These individuals were not considered to be team members
and, with the occasional exception of the physician's
wife, did not attend team meetings.

5. Training for medical practice as a pediatric cardiologist
encompasses nine years: four years of medical school,
one year of internship, two years of pediatric residency,
and two years as a pediatric cardiology fellow.

6. The eight most common types of congenital heart disease
dealt with in the CHP (comprising over 90 percent of the
cases) were Ventricular Septal Defects, Atrial Septal
Defects, Patent Ductus Arteriosus, Coarctation of the
Aorta, Tetrology of Fallot, Complete Transposition of the
Great Vessels, Pulmonary Stenosis, and Aortic Stenosis.

7. Of the eleven clinics, eight were held in public health
facilities, one in a migrant clinic, and two in the
offices of private physicians. The closest clinic to
South City was forty miles away; the others were 90 to
140 miles distant.

8. During its first two years of operation, the program
encountered many difficulties in the form of administra-
tive fights with the hospital bureaucracy. These "has-
sles" came in the form of attempts by the hospital ad-
ministration to limit the team's autonomy and concerned
such issues as supervision, salaries, access to medical
records and general grant disbursement. In the words of
the physician, there was a "war on" between the CHP team
and the Children's Hospital. In 1974, when the sociolo-
gist and second anthropologist arrived, most of these
issues had been settled to the program's satisfaction.
Occasional skirmishes continued, but everyone agreed it
was "nothing like before."

9. Patients were referred to the CHP by private physicians,
public health physicians and nurses and school nurses.

10. The induction of new team members is frequently mentioned
in team literature as a time of "stress," for, as time
passes, teams begin to have a life of their own which is
disrupted by changes in membership. Teams develop and
enforce a set of norms (Rubin and Beckhard 1972) and each
team comes to have a history which influences the careers
of subsequent team members (Horwitz 1969; Lamberts and
Riphagen 1975; Richards 1970). As a result, there is






-64-


always a period of readjustment with the addition of new
team members in which an awareness of the subtleties of
team interaction will aid the newcomer (New 1968).
Mills (1967) discusses the induction of a new member
into a small group in detail by relating the subjective
experience of the group's individual members to the five
levels on which group process occurs. A "stranger" to a
group begins to operate first on the level of behavior
and feelings. He does this by watching others for cues
and by modeling the behavior of those around him. The
next level of integration into the group comes when the
newcomer learns the "rules," or group norms, which stand
behind the group's behavior and feelings. The following
stage of joining the group involves the newcomer's under-
standing and accepting group goals to the point of
placing them above personal goals. Finally, the newcomer
adopts group values, an action encompassing an over-
arching concern for the welfare and survival of the total
group.

11. Such awareness did not mean that team members had neces-
sarily freed themselves of the influence of history. As
the physician noted two-thirds of the way through the
nine month contractual period of the new social scien-
tists: "A great deal of the way I feel is still colored
by my exposure to the first anthropologist."

12. On another occasion she explained our position to an
outsider:

They were new in the program and didn't know
what to expect. I think they felt like they
were just left out in the cold. Nobody of-
fered to help them, nobody made any effort to
invite them in or help them feel like part of
the team.

13. In all these actions, the social scientists were seen as
"uncooperative." This is demonstrated in the following
statement made by a medical team member after the social
scientists had been with the program for some months:
"You have improved, you are not so demanding." This
issue will be further dealt with in Chapter V.




















CHAPTER III
THE CHOICE OF METHOD OF STUDYING
TEAM FUNCTIONING


The purpose of this chapter is to discuss the rationale

for choosing a qualitative research method rather than a

quantitative one, and to offer a detailed outline of the

actual research approach adopted. A qualitative approach

was selected because of the clear advantages of qualitative

over quantitative methodology in the CHP research setting.

Although quantitative methodology is usually employed in

agency settings, it suffers from a number of limitations in

this instance. These are conveniently grouped into four

categories: context, sample size, goal definition and re-

search implementation. Each will be discussed in turn.

After establishing the basis for choice of methodology, we

examine the specifics of the research process utilized in

this investigation of the CHP team.

Qualitative Evaluation Research

Context

Because the subject of teamwork collaboration has not

yet been examined thoroughly, there is no body of theory on

which to rely. Any methodology adopted in such circum-

stances must be necessarily exploratory, and qualitative


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methodology most effectively satisfies the need to explore.

Quantitative evaluation research would tend to generate

statistical results divorced from proper understanding of a

program's social context. By uncritically accepting the

results of quantitative testing, evaluators often produce

studies of low validity. For example, in studying a health

care team, an investigator might correlate individual team

members' need for achievement with their collaboration in

team activities. In doing so, he might discover statis-

tically significant differences but never ask whether fac-

tors other than need for achievement might not be more

important in determining the course of team cooperation.

Because of problems such as this, quantitative research has

recently come under heavy attack, with some critics sug-

gesting that quantitative methods be supplemented or sup-

planted by qualitative research (Popham 1982).

Several social scientists argue in favor of using a

specifically qualitative approach to applied research in

order to take program context into full consideration.

Donald Campbell is perhaps the most prominent proponent of

this change in orientation toward qualitative methodology.

He states that the present division of labor into qualita-

tive and quantitative "camps" is unhealthy and argues that






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case studies will catch unanticipated side effects more

structured approaches might miss.1

Arguing along the same lines, R.S. Weiss and Martin

Rein have produced the most frequently cited alternative to

quantitative research evaluation. They refer to their ap-

proach as "process-oriented qualitative research" and call

for careful description of the "before, during and after" in

introducing programatic changes (1972, 1977). Gerald Britan

advocates much the same approach, using the term "contextual

evaluation" (1978). All agree in noting that exploratory,

problem-oriented ethnographies increase the chance of hit-

ting upon variables critical to an understanding of the

process of planned change.

In contrast to quantitative research, qualitative in-

vestigation seeks not to predict but to understand behavior

(Mullen and Iverson 1982). Rather than attempting to estab-

lish the existence of predicted correlations between certain

factors, for example, a qualitative study of a health care

team would examine the broad research setting in a search

for the factors of most significance in establishing col-

laborative team efforts. This has been an important aim of

this study.

Restated, qualitative methodology is exploratory. It

allows the researcher to shape and reformulate more precise-

ly those questions that need to be asked, prior to asking





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them. The information gathered may then be used in building

middle-range theories. After such theories have been estab-

lished, they may, of course, be tested for verification with

quantitative methodology.

Sample Size

The second case in which quantitative research is inap-

propriate occurs when the research population is small

enough that it can be easily examined by one researcher.

Bennis, for example, supports the qualitative case study as

a proper means of program evaluation (1968). He notes that

experimental sciences require quantitative research designs

because they assume the process they are studying goes on in

a "black box." Bennis concludes by remarking that when it

is possible to observe throughout the experiment, the need

for the experimental model is bypassed. Such is the case in

this study of the CHP team. Because the research population

is very small (N=12), it is possible to study all team

members and to investigate most aspects of team life.

Goal Definition

A third difficulty in using quantitative evaluation

research occurs when investigating "broad aim" social pro-

grams in which program goals are diffuse and unoperation-

alized. Because current programs often have goals that are

global in nature, attempts to identify and further define






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these goals often produce a major stumbling block in car-

rying out health and social services research.2 In the case

of this study of teamwork, the team goals are defined but

diffuse: "delivery of interdisciplinary health care." In

order to carry out quantitative research it would be neces-

sary to define the goals more precisely and to operation-

alize them so that criteria for their achievement could be

established (Blalock 1972). In this particular teamwork

study, however, such an exercise might bypass consideration

of such issues as whether the "team" was even operating

according to commonly accepted definitions of teamwork. A

quantitative approach is therefore also inappropriate with

regard to this aspect of investigation.

Research Implementation

The fourth problem in utilizing quantitative evaluation

research revolves around difficulties in administering re-

search in action settings. Because controlled experiments

were originally developed for use in laboratory settings, it

is often impossible to transfer them intact to agency set-

tings where research conditions cannot be easily controlled.

There are, for example, often planning or programmatic con-

straints. Many program administrators refuse to allow ran-

dom assignment to social programs because they do not want

to withhold treatment from anyone. This classic design also

demands that the program remain constant over time and many





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program directors are unwilling to have their flexibility

restricted in this manner.

As a result, quasi-experimental or non-experimental

research designs must often be used and these sometimes have

severe methodological problems of internal validity (the

ability of the research design to yield an unbiased estimate

of the effect of treatment) and external validity (the

extent to which the research findings are generalizable to

the population which the policy will affect). Evaluators

often try to overcome these methodological weaknesses by

using a "patched-up design" in an attempt to rule out all

sources of error (Weiss 1972).

In this particular study of teamwork, the shift in the

overall program presented the fourth barrier to quantitative

research. The team was not a static entity. Instead,

members' responsibilities were fluid and varied as a conse-

quence of the program development efforts in which the team

constantly engaged. This aspect of the team's nature pre-

sented a final reason for selecting qualitative over quanti-

tative methodology.

An Overview of the Fieldwork Situation
and Data Generation on the CHP Team

The foregoing section argues for qualitative research

as a more appropriate method for studying this particular

interdisciplinary/interprofessional health care team. Par-

ticipant observation was the specific approach adopted,





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supplemented by open-ended interviewing as the research

focus narrowed. Michael Agar's description of the research

process as a narrowing "funnel" provides a useful means of

describing the course of analysis of the CHP team (1980).

At the beginning of the research, I adopted a broad outlook

by examining every aspect of team life. As my research

continued and I gathered new materials, I developed hypo-

theses. After gathering yet more data, these hypotheses

were either reworked and retained, or discarded. This pro-

cess continued until the field of research narrowed to a

select few propositions about teamwork which then became the

focus of research activities. At this point, the hypotheses

I developed in earlier stages of research were tested in

depth. The funnel analogy, then, is appropriate: a begin-

ning wide-open approach was gradually replaced by concen-

trated examination of those factors withstanding initial

hypothesis testing. In this manner, my hypotheses were

allowed to grow from detailed understanding of the field

research situation.3

In the first and broadest stage of my research, I

investigated many aspects of ClP team life. Being concerned

with establishing myself as a researcher and member of the

CHP team, I sought orientation by gathering information

about the team's history and present situation. To this

end, and throughout all my research, I examined behavior





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(what people did--real behavior), speech (what people said

should be done--ideal behavior), and the products of be-

havior (what people had--archival material).

In seeking to orient myself specifically to team opera-

tions, I observed the activities of all team members. For

example, I attended all program meetings, went on trips with

the team to screening clinics located in other towns, and

watched x-ray procedures, a heart catheterization and heart

surgery. I was informally introduced to all program person-

nel as well as to personnel from other clinics who were

working in cooperation with CHP staff. More formal intro-

ductions were arranged with the administrative and clinical

directors of the hospital, the chairman of the hospital

board of directors, the director of nursing, the chief of

residents, the hospital biostatistician and the previous CHP

team anthropologist. In these formal meetings discussion

centered on the history and current position of the CHP

within the hospital.

By the second stage in my investigation, I was oper-

ating with a general understanding of the team's history and

functioning, and I began to narrow the funnel of my research

activities. I was not concerned with the formation of

initial hypotheses. By this point, I was becoming aware of

the existence of separate subcultures within the team: one

formed by the medical personnel, the other by the social





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science staff members. I was also beginning to sense the

overarching dominance of medical values within the team.

Feeling that the existence of either medical dominance or

subcultures might have a decisive impact on team collabora-

tion, I began an attempt to document the influence of these

factors. At the same time, I searched for other factors,

such as personality and ethnicity, which might be of equal

or greater importance to team operations. In a sense, my

discovery of the "life and times" of the two program subcul-

tures provided a creative tension spurring me on to seek a

deeper understanding of team dynamics.

In my position as team anthropologist I was now oper-

ating as both participant and observer. I had total access

to all team data, such as program records and statistics, in

this small group setting. Because the population was finite

and small (N=12), there was no need for sampling. I was

able to observe and record much that occurred around me in

the daily process of team life.

I attended all team meetings and functions in the

company of my pencil and pad, which I put to use in taking

notes.5 I took notes openly in formal meetings and informal

discussions. If, however, conversations were confidential

or controversial, and I felt that open note taking might

hamper free discussion, I would reconstruct the conversation





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at a later time. All of my notes, both on-the-spot and

reconstructed, were typed into my daily fieldnotes.6

Throughout my gathering of information and note taking,

I watched for patterns of behavior to emerge. In the pro-

cess, I constructed records for myself, such as seating and

activity charts. For example, I recorded the travel of all

team members on a monthly chart, in order to establish a

rough index of the amount of program time devoted to

funding. During this phase, I also collected program docu-

ments such as grant proposals and statistics on the number

of patients seen. I was especially careful to collect all

written material in which the program described itself, for

either granting or public relations purposes.

Another part of my research was carried out in classes

which the sociologist and I taught to program and hospital

medical personnel. These hour-long classes, thirty-five in

all, were organized as semi-structured lecture/discussions

of various aspects of the relationship between social sci-

ence and medicine. They were taped.

Yet another opportunity for discussing problems of team

collaboration arose when the team embarked on a series of

team development sessions designed to improve team opera-

tions.7 By this time team members had become aware of

problems of collaboration, possibly as a result of my fo-

cusing on this as a topic of research and certainly because





-75-


of difficulties experienced in incorporating the sociologist

and anthropologist as new team members. These seven two-

hour sessions covered concrete aspects of teamwork, such as

program goals, staff roles and coordination and negotiation

between team members. They were also taped and transcribed.

The third and final stage of my study consisted of

applying the various analytic concepts developed during the

second phase of my research in order to see what sense they

made of the data I had collected. Narrowing my research

project to a concentrated investigation of those factors I

had determined to be most important to team collaboration, I

constructed and administered a semi-structured interview

schedule (see Appendix A). This schedule was designed to

investigate each team member's perception of possible fac-

tors affecting team collaboration which I had pinpointed in

the previous stage of research. Here, as in all my re-

search, I did not interview only key informants. I inter-

viewed everyone, both from within and from without the

program, who seemed connected to or concerned with program

operations. This activity yielded forty hours of taped

interviews.

After gathering the information from my interview

schedule, I checked its reliability by asking for evalua-

tions of team functioning by outsiders called in as tempor-

ary consultants to the team. For example, the team had





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hired a documentarian-photographer to produce a slide-tape

presentation on the program's team functioning. He also

interviewed all team members on problems associated with

team functioning shortly after I completed my interviews,

and he cooperated in giving me a copy of his tapes. His

comments and interviews were a valuable aid in checking the

validity and reliability of the information I had gathered.

I was also able to check the validity of my analysis by

observing the hiring and induction of a new anthropologist

health team member. I continued to have informal discus-

sions with various team members concerning problems of team-

work throughout all phases of my research.

Summary

Qualitative research was selected as the most appro-

priate methodology for this investigation because of four

contraindications to a quantitative approach. Restated,

they are: (1) little is known about the dynamics or context

of teamwork; (2) the sample size (N=12) was small enough to

allow thorough investigation of all research subjects; (3)

the program goal was too broad and diffuse to research

easily; and, finally, (4) it is difficult if not impossible

to implement quantitative research in action settings.

To conclude, a quantitative methodology would not have

generated either the necessary or sufficient information to

obtain adequate results. Hence, a qualitative methodology,


I





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organized in the form of an ever-narrowing funnel, did

provide an effective approach to studying the CHP team.

Because team operations had not yet been fully subjected to

social science inquiry, it was first necessary to carefully

examine the dynamics of this particular health care team.

Qualitative methodology provided a strong tool for assessing

day-to-day team operations and thus for defining influential

factors. The factors which were pinpointed during the

course of the research as having the most impact on team

collaboration will be discussed in detail in the following

chapters of analysis.


Notes


1. Campbell (1978) still believes quantitative data can go
beyond qualitative in subtlety, but also states that if
these two sources of data are ever in conflict the pro-
gram evaluator should throw out the quantitative data.

2. Ambiguous and conflicting goals can cause a program to
fail even before it has begun. In their evaluation of a
Skid-Row Alcoholism Program, Lincoln Fry and Jon Miller
(1977) discovered that because staff members were unable
to specify an agreed-upon goal they were unable to imple-
ment program objectives.

3. Barney Glaser and Anselm Strauss (1967) discuss detailed
strategies which may be used in generating theory from
qualitative data. Their particular approach, called
"grounded social research," is utilized in this study of
team collaboration. In this kind of inductive research,
both the research situation and methodology are depen-
dent. In other works, the data collection and analysis
are done concurrently.

4. This description of the focus of my research is taken
from Pertti Pelto (1970). The collection of papers
edited by Raoul Naroll and Donald Cohen (1973) is another





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useful source of general information on method. Hortense
Powdermaker (1966), Myron Glazer (1972) and Michael Agar
(1980) have all written excellent books covering the
process of qualitative research. John Brimm and David
Spain (1974) discuss the use of quantitative research in
anthropology. In the past, anthropological method has
often gone unexamined. The books listed above indicate a
change in orientation. Fieldwork, always a rite of pas-
sage for anthropologists, is now being closely examined
as a data gathering technique.

5. Staff members became accustomed to my constant note
taking. A team member once remarked: "Linda, you're
always there, you and your notepad."

6. In gathering the data for this study, I produced roughly
180 pages of single-spaced typed fieldnotes.

7. This program was developed by Irwin Rubin, Mark Plovnick
and Ronald Fry of the Massachusetts Institute of Tech-
nology. Entitled "Improving the Coordination of Care: A
Program for Health Team Development," the authors
described their training booklet as
a program of task-oriented activities aimed at
helping any group of health workers and/or
administrators responsible for the delivery of
health care to get its job done in the most
effective way possible. This program focuses
on specifically defining the job that needs to
get done and procedures for doing it. (Rubin,
Plovnick and Fry 1975:4)

8. At various points during my tenure with the CHP I spoke
in depth about program operations with four outsiders who
had contact with the CHP. These were individuals hired
by the CP to do consulting work or to produce some
service for the program.

9. This anthropologist, the third to be hired by the CHP,
was selected at the beginning of my second year with the
program when I was working as a consultant to the team.
At that time I was living in Mexico City and commuting to
South City for several days each month. I was the person
in charge of coordinating the search and hiring pro-
cedures for the anthropologist, who was expected to take
my place as a full time team member.




















CHAPTER IV
TEAM SUBCULTURES AND MEDICAL DOMINANCE
IN THE CHP TEAM


The purpose of this chapter is to delineate, with

examples, the operation of one particular interdiscipli-

nary/interprofessional team, the CHP team. The particular

aim of this ethnographic effort is to demonstrate the vital

need to understand the internal dynamics of team behavior.

As discussed earlier, an anthropological approach focusing

on culture was deemed an effective method for analyzing the

workings of an interdisciplinary/interprofessional health

care team. Although teamwork has received increasing inves-

tigative emphasis in recent years, substantive research on

team operations has been neglected. Despite this research

gap, the supposed advantages of teamwork have been promoted

in countless descriptive articles and health care teams have

become a kind of fad. Most health care teams have been put

into operation without careful assessment of their value and

goals.

In light of this, the application of the anthropologi-

cal concept of culture has two advantages: first, it fo-

cuses attention on the presence of two separate subcultures,

the medical and the social science; and, second, it provides


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-80-


a technique for analyzing the relationship between the two

subcultures, and therefore of explaining team operations.

The key to understanding that relationship is the over-

whelming dominance over the "minority" social science sub-

culture by the "majority" medical subculture.

In recent years, small group research has received

concentrated attention, and on first approach seems to pro-

vide a useful means of understanding team process. This

appears not to be the case, however, since teams differ in

significant ways from voluntary small groups. Small groups

based on voluntary association tend to run on the basis of

consensus. In contrast, teams often find that members,

leaders and roles are assigned by the larger organizational

or bureaucratic system of which the team is a part (Golin

and Ducanis 1981). As a result of this forced association,

teams are usually formed of individuals from many different

educational and work backgrounds, or "cultures." A subcul-

tural approach is necessary, then, because interdiscipli-

nary/interprofessional teams are not simply small groups.

Team members from dissimilar backgrounds have difficul-

ty understanding both the methodology and the area of exper-

tise of those from professions or disciplines other than

their own. Forced into a working association as part of a

team, team members may find themselves forming into any

number of coalitions or subcultures within the team.





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Interdisciplinary/interprofessional teams are composed of,

at a minimum, two or more subcultures: one formed of re-

searchers, the other of practitioners.

My discussion of the majority/minority subculture re-

alities of CHP teamwork relies on the careful interweaving

of extant pertinent social science reports with my own

extensive fieldwork-based observations. The existence of

differing goals and values within teams results in the oft-

noted problems of team conflict. Within the CHP team, I am

calling these goals and values subcultures. In a setting of

differing subcultures, team conflict is inevitable and team

discord the predictable result.

In utilizing the concept of subcultures to explain team

conflict, there is an additional factor which must be con-

sidered--status. One subculture may dominate another if its

members possess higher status by virtue of their membership

in a certain profession or discipline. Status differentials

have a powerful impact on the negotiations which occur

between team subcultures, particularly with regard to the

role which the members of each will be allowed to play in

team operations. Within the CHP team, the two subcultures

were ordered by medical dominance. As a result, members of

the social science subculture found themselves required to

interpret and adapt to medical demands.





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Medical and Social Science Subcultures
in the CHP Team

Although dissension in health care teams has been

thoroughly documented in team literature, to date no social

science researcher has explicitly used the concept of cul-

ture to produce a theory which adequately explains team

conflict. Both C.P. Snow (1961) and George Foster (1962,

1969) have discussed the existence of professional and dis-

ciplinary subcultures in the modern work-a-day world. Nei-

ther of the authors, however, has applied his ideas to the

common problem of conflict in health and human service

teams.

In the following analysis and interpretation of the

field data and pertinent literature, the term culture refers

to "learned and transmitted motor reactions, habits, tech-

niques, ideas and values" (Kroeber 1948:8). In other words,

culture constitutes a set of "rules" for the behavior of its

members. Subcultures are subgroupings which have differing

goals and values. They have their own rules for living,

with reference to behavior and attitude, which differ from

those of the larger culture as well as from those of other

subgroups.1 In the case of the CHP, all team members are

Americans. Specifically, the team studied formed two sub-

cultures of this larger culture, rather than the single,

health/work-oriented subculture one might expect.






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The most jarring discovery of this field investigation

was my realization of the extent to which the CHP team

actually functioned as two teams. Although the team pre-

sented itself to outsiders as a cohesive unit, close exam-

ination revealed that there were really two separate yet

cohesive teams, each of which formed a subculture of the

larger CHP team, or overall team-culture. One subculture,

indeed the "majority subculture," was composed of members of

the health professions; the other, or "minority subculture,"

of personnel from the social science disciplines.2

Members of the medically oriented subculture included

the physician-director of the program, a pediatric cardiolo-

gist; four Mexican American nurse practitioners, certified

as both nurse practitioners and "pediatric cardiology asso-

ciates;" a social worker; a technician-administrator, also

chief of the EKG-EEG staff at City Hospital; a secretary-

coordinator; and a public relations consultant. The social

science group included an anthropologist (LCI), a sociolo-

gist and an economist (see Table 4-1).3 The social worker

is included as a member of the medical subculture because

social workers have been traditional members of practicing

"core" medical teams while individuals from other social

science disciplines, with the exception of clinical psy-

chology, have not. The CHP team social worker was a practi-

tioner and thus similar in behavior and attitude to other






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medically oriented staff. In contrast, members of the so-

cial science team were researchers.





TABLE 4-1
Division of the CHP Team into Subcultures


CHP Team


Medical subculture Social Science subculture


physician-director anthropologist
4 nurse practitioners sociologist
social worker economist (part-time)
technician-administrator
secretary-coordinator
public relations consultant
(part-time)


This division into subcultures was informally acknowl-

edged by all team members. For example, during an early

team meeting in which problems of teamwork were being dis-

cussed, a medical team member pointed out the pattern of

subgrouping:

You three [social scientists] communicate with
each other. You talk, go to lunch and socialize
as a group. On the other hand, the rest of us
always stick together.

In daily terms of reference, all medical team members,

including the social worker, referred to the anthropologist

and sociologist (the two full-time social scientists) as the






-85-


"social science team." Further discussion of this clus-

tering pinpointed the division between the social science

and medical subcultures as being based on work activity. A

second medical team member noted: "The rest of us are tied

together very closely. We work together as a team and we do

have more communication."

Yet another team member then remarked that the lack of

communication between social science and medical personnel

was aggravated by the fact that the sociologist and anthro-

pologist were sharing an office separated from other members

of the team. The economist also spent a lot of his time in

this office during his weekly consulting trips. The team

decided to rearrange its office space as a result of this

discussion. The anthropologist and sociologist moved into

an office area which they shared with the secretary-coor-

dinator, thus putting themselves at the hub of team activi-

ties. This move helped alleviate but did not solve problems

of team collaboration.5

Although team members acknowledged these groupings,

they were not fully conscious of their significance with

regard to team collaboration. Closer examination of subcul-

tures, however, yields striking differences in behavior and

attitudes, which will be fully examined in Chapter VI. It

was as though there were two teams rather than one. Members





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of each subculture were in daily close association, as they

worked, talked and ate together.

The distinction between medical and social science

subcultures reflects the separation between academic social

science disciplines and medical professions. The social

scientists were all members of social science disciplines

(economics, sociology and anthropology) in which the goal of

research received high emphasis. On the other hand, the

medical personnel had all received professional training

stressing practical aspects of providing medical and psycho-

logical therapy to patients. In medically oriented profes-

sions, practitioners receive training and are then certified

(by an R.N., M.S.W., or M.D. degree) as being capable of

performing certain technical, medical or psychological pro-

cedures. In contrast, students in disciplines study a dis-

ciplinary area of thought and are then certified (by an

M.A., M.S., or Ph.D. degree) as being capable of performing

research in that discipline.

This separation between medical professions and social

science disciplines was made clear by the comments of one of

the nurse practitioners who pointed out that the social

science team members were connected by "academia stature

[sic]." He observed, not uncritically: "You are all work-

ing--supposedly--on your Ph.D.s, so you all have similar

interests."





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Medical Dominance in the Health Services

A brief examination of medical dominance in health

service organizations illuminates the workings of the CHP

team. Two subcultures within one team might co-exist peace-

fully if they sought common goals. When one subculture

dominates the other, however, collaborative relationships

tend to be inhibited. Use of the theme of medical dominance

in research is not new. Medical dominance in general, and

physician dominance in particular, have been topics of ex-

tensive theoretical research by the sociologist Eliot Fried-

son (1970a, 1970b). It has become such a familiar subject

that it is mentioned in nearly every article treating health

care teams. Within the CHP team, medical dominance

functioned to create a situation in which the social scien-

tists, as members of a separate subculture, were isolated

and felt unappreciated.

Physician and Medical Dominance in the CHP Team

Like other teams described in the review of the litera-

ture in Chapter I, the CHP team was subject to medical

dominance. Medical, or clinical dominance6 determined near-

ly every aspect of the structure and operation of the team.

The CHP team, moreover, was particularly subject to domina-

tion by the physician. Dr. X's dominant role was revealed

in a number of ways. It was he, for example, who held the

formal title of "project director" and he was introduced in





-88-


this manner as the senior member of the team. The team

itself was known within the hospital and in the local com-

munity as "Dr. X's health team."

The dominance of the physician was most clearly re-

flected in the amount of attention he received from all

staff members, particularly those from the clinical compo-

nent of the team. The question of concern to most team

members in accomplishing their goals was: "What kind of

mood is he [the doctor] in today?" This issue was often

raised in discussions which team members held among them-

selves: "Are we [meaning "is he"] really in the mood? I

would hate to pick the wrong mood." The following exchange

provides another example of this focus:

"Ta-Da! He's here!"
"Who, God? Jesus Christ Superstar?"
"I didn't say God. I said 'He's here.'"
"Well it's 'He' with a capital H, isn't it? Who
is that but . ."

Medical staff members were very aware of and concerned

with the doctor's actions and opinions. For example, when-

ever the social worker was approached with new ideas for

program projects his response was usually: "I wonder what

Dr. X would think about that?" Another example of respect

accorded the physician's wishes occurred when the anthro-

pologist received what she suspected was an inappropriate

counseling referral. The physician had referred the father

of a 14 year old mongoloid patient on the grounds that he






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was showing "excessive affection" toward his son, by holding

him on his lap and hugging and kissing him in the examining

room. The anthropologist talked this case over with the

nurse practitioners, suggesting that emotional demonstra-

tiveness might vary from family to family, and ascertaining

that this "problem" had no readily apparent bearing on the

child's health. The anthropologist then stated that she was

going to talk to the physician about the inappropriateness

of this referral. "No," said the nurse practitioners, "If

the chief says do it, do it." The anthropologist complied.

The following example further documents the pervasive-

ness of the medical dominance over team activity. On one

occasion, a nurse practitioner explained why staff had to

"hustle" when Dr. X called them on the phone: "When the

chief calls and asks a question, he wants to know the answer

now. He doesn't want to know that we don't know either."

These responses to the medical team's perception of the

power situation underlay the remarks of another medical team

member who stated flatly: "People don't disagree with Dr.

X."

Dr. X did not actively seek deference from team mem-

bers. As one of the social scientists pointed out, he was

very "horizontal" in his work orientation. It was the

physician's desire to include all team members in team

projects so that they might all "develop and reach their





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full potential." In following this principle, he gave the

team secretary responsibilities as "coordinator" and, in a

hospital meeting of the paraprofessional committee, asked

why the janitor was not being included in a discussion of

hospital morale.

Dr. X sought the opinion of others and listened re-

spectfully. He observed, for example, that he admired the

anthropologist "for not being afraid to state her opinion

and, having stated it, to stick to it." His reflection

suggests that such an occurrence was unusual enough to be

cause for comment. Although social science team members

were not afraid to approach the physician, medical team

members were more timid. Even if Dr. X did not seek auto-

matic deference from the medical team, he was accorded it.

Although the physician did not desire absolute defer-

ence, he was cognizant of his elevated status within the

team. He was, for example, very aware that team members

were not, as he once mentioned during a team meeting, his

"real peers." He seemed to imply by this statement that

only other M.D.s were his true equals.7 Occasionally he

would mention his educational background during team discus-

sions by way of explaining why the team should do as he

wished: "I'm 16 years past high school in college and

medical school and medical education."