Cultivating a Culture of Camaraderie and Cohesiveness in Your Pediatric Hospital Medicine Team

Creating a work environment in which team members feel supported and valued can increase job satisfaction and facilitate finding joy in the everyday practice of medicine.1 Camaraderie serves as a vital element in building morale within a team, and cohesion is the unity within a group encompassing both social integration and task-oriented collaboration.2 Cohesion is further characterized by the robust bonds connecting members to the group and the profound sense of belonging and community it engenders.2 Such a culture of cohesiveness and camaraderie benefits both the individual and the system at large with decreased physician burnout, easier hiring practices, and more long-term retention. Additionally, some literature supports that increased physician well-being may lead to higher-quality patient care.3 As the pediatric workforce recovers from the personal and practice demands caused by the COVID-19 pandemic,4 the need for such a supportive work environment is critical for providers.Located at a large, quaternary care, free-standing children’s hospital, our pediatric hospital medicine (PHM) division has experienced steady growth over the last 40 years from a handful of original founders to now over 30 physicians. Despite this expansion, it has kept the culture of a small group practice in which all the members have a sense of ownership and belonging. In fact, in a study of national PHM providers conducted in 2020, our division showed higher mean work engagement scores (4.91 vs 4.36, out of the 6-point Utrecht Work Engagement Scale) and lower rates of burnout (24% vs 36%, using the Mini-Z burnout measure) than our counterparts nationwide.5,6 Additionally, attrition rates for our group have remained relatively low, with 17 faculty departures over the last 10 years, or an average of about 6% turnover. Of note, 3 of those 17 have been for retirement, 3 have been to matriculate into a subspecialty fellowship, 3 have been to take leadership positions outside of our division, and 5 have wanted to move closer to family, leaving only 3 who left to pursue a similar PHM position elsewhere or left PHM altogether.In this perspective article, we will explore the characteristics of a supportive environment that have been realized through many successes (and some failures) of our long-standing division. We will use the metaphor of a three-legged stool—commonly used to refer to the research, educational, and clinical pursuits in academic medicine—of team, translation, and trust to demonstrate how leaders and group members can contribute to a culture of camaraderie and cohesiveness. We will also identify potential barriers and suggest strategies to overcome them. Ultimately, we aspire to assist leaders in fostering an environment of wellness and professional fulfillment within their own institutions.Camaraderie and cohesion must first have a team through which to grow. A successful team is rooted in inclusion and commitment to shared values, cultivating a culture of “we.” When team members experience this sense of belonging, they wish to contribute to the triumphs and responsibility of their team. During the recruitment of new faculty, our division leads with our mission statement and provides examples of its manifestations. By spotlighting our values, we aim to attract team members who share and practice these values while expanding our collective ideas and potential.To maintain a culture of “we,” all voices are not only heard but also sought out and genuinely valued. We formally elicit individual voices during weekly division-wide meetings (eg, business meetings, journal club, guided group reflections, and our diversity, equity, and inclusion curriculum), one-on-one and small group meetings with the division director throughout the year, and through the regular use of electronic, anonymous surveys. Demonstrating the value of these voices occurs through the encouragement of team brainstorming followed by division-level change after thoughtful contributions.Our division creates ample space for casual exchange of ideas and social relationship growth as well. Examples include reservation of our conference room for social lunch hour, hosting weekday afternoon coffee hours, and practicing an open-door policy, which invites conversation within our office suite. Team building starts with a thoughtful onboarding process and extends beyond the walls of the hospital. We host family-friendly weekend social events to welcome new faculty (eg, fall Soup-er Bowl), winter wellness parties (eg, karaoke, holiday cookie decorating), book club events, and impromptu happy hours. Our division has found that through psychological safety and appropriate playfulness in the work environment, multidimensional connections emerge and strengthen our team’s cohesion.In this realm of building community, “translation” refers to how the group communicates and interacts with the administrative arm of the health care system. As the leader of the group, the division director takes the primary responsibility for this translation, although that responsibility can be shared among members with specific administrative responsibilities (eg, clinical services director or vice-chair for faculty affairs).Through leadership changes over 35 years, we have identified division director characteristics that have benefited the group’s cohesion. Guarded transparency, the skill of balancing openness with discretion, is chief among these attributes. Leaders must provide sufficient information to build upon a unified mission and vision while remaining mindful of the administrative complexity that often leads to uncertainty in the earlier stages of decision-making. This guarded transparency avoids confusion or resentment when the course of a decision is diverted, reversed, or eliminated.A key element of translation is how administrative demands are communicated to the team members. We have found the most success when we discover ways to tie administrative messaging into our division’s mission. For example, our group, which serves as the primary service for approximately a third of the non-intensive care unit patients admitted to our hospital, received a requirement to substantially increase our percentage of discharges before 11 AM. To achieve this goal, we needed to rearrange clinical shifts and require formal multidisciplinary conversations around discharge preparedness. Our team, aware of skepticism in the literature about the impact of earlier discharges on patient throughput,7 struggled to conceptualize the importance of this demand related to the increased effort required. However, when communicated in a way that connected this process to helping patients get home sooner and more smoothly, maximizing their time out of the hospital, and minimizing time away from school and parents’ work, our group felt a sense of purpose and greater motivation to accomplish our given goal.In times of uncertainty, our leaders always try to provide clarity and maintain a sense of hope. Genuine gratitude for the hard work of group members fosters belief in the group and its leadership, although our group has also experienced a loss of trust in institution leaders when that gratitude seems disingenuous. Our division leaders display fairness in decision-making, soliciting and incorporating input from other group members whenever possible. For example, a change in the structure of our holiday schedule was implemented after group members voted on their preferences. Not every decision can be made via the democratic method, but when applied, this can increase the group’s sense of agency, engagement, well-being, and trust.Trust in a hospital medicine division refers to psychological safety, mutual respect, and the belief that everyone shares similar professional values. Trust also extends to the belief that the leaders serve the best interests of the group members, patients, and the institution. When trust is present, team members are more likely to work together effectively, communicate openly, and support each other through challenges.Conflict is a normal and expected occurrence in any workplace setting, and how conflict is addressed and resolved can significantly impact the overall culture of the workplace. When conflict arises, it is important to engage in conflict resolution strategies that promote active, respectful listening such as clarifying the issues at hand, remaining impartial, and considering the perspectives of all key stakeholders. One effective strategy for resolving conflict is to have the parties agree on a common goal. This centers everyone on similarities and the “why” underlying the dispute. When conflict arose regarding the staffing of our direct care team, division leadership created a menu of administration-approved staffing solutions (eg, hiring a nocturnist, redefining shift durations, redefining the weighting system for off-hour shifts), many of which were born from brainstorming with direct care team members. These solutions were presented to all involved providers of this team and followed by an anonymous survey to ensure that all members had opportunities to share their perspectives and vote on the final staffing decision. Conversations surrounding these staffing options uncovered a need to rebuild cohesion within this group, and a summit conference was scheduled for all members. Leadership ensured that summit attendees had no concurrent or immediately preceding clinical responsibilities, reviewed the importance of psychological safety, and mediated a group conversation centered on the shared values defined by this provider subset. Such efforts lead to stronger relationships, improved communication, and a more harmonious work environment.Measuring the success of team-building efforts is crucial to ensuring that endeavors are worth the labor. Leaders and team members can reflect on internal data, such as exit interviews, frequent small group meetings, or survey-based measures of burnout, well-being, and/or engagement, to judge cohesion and amicability within the group. These types of measures can serve as effective guideposts on the journey of building camaraderie.Fostering camaraderie and cohesiveness within a health care organization is paramount and can mitigate burnout, enhance job satisfaction, and improve patient care. The metaphorical three-legged stool of team, translation, and trust serves as a guide for leaders and team members alike. Through member engagement, transparent leadership, active listening, and collaborative problem-solving, institutions can cultivate trust, strengthen relationships, and create a supportive work environment conducive to professional fulfillment and personal growth.