What we learned in kindergarten : five tips for collaboration in oncology

Ask any colleague how she or he is, and the answer is invariably a shrug of the shoulders and the word “busy.” We are all trying to balance our commitments inside and outside of work, and many of us are evidently not getting that balance right. It should not be surprising that, among physicians caring for cancer patients, burnout and job dissatisfaction are increasingly being recognized1. Despite that recognition, it appears that physicians rarely take proactive positive steps to improve things in either their home or their work life; most take corrective action only at times of crisis. Our team has tried over the years to provide practical guidance on a diverse range of topics affecting quality of life for oncologists: physician happiness2, career guidance and mentorship3, and retirement planning4. In reflecting on the various areas of life that can lead to general dissatisfaction, a common theme for improvement appears to be collaboration. Humans are social creatures, and collaboration is therefore essential in all areas of life. However, sometimes at work, as in any relationship, an awareness of personal shortcomings is often missing. This article therefore focuses on collaboration in oncology. Although common themes such as courtesy and respect should be obvious to all of us, such clarity is unfortunately not always the case. It therefore seems appropriate to be reminded of some fundamentals once again. Kindergarten was a time when we learned the foundations for social interaction: a place where friendships were formed and dissolved ... a place where dreams were explored, encouraged, or sometimes crushed. Kindergarten was the place where we created, shared ideas, and learned to love, trust, and depend on people outside of our family unit. Those early lessons helped to shape our future adult behavior and development. Somewhere along the way, however, when we supposedly “grew up,” we often forgot the original lessons that once served us best. Although we wouldn’t be so naïve as to assert that preschool teaches everything needed to understand human interactions in the work place, our thought is that we all could perhaps benefit from a little refresher. As an appropriate guide to self-reflection in this area, we chose Robert Fulghum’s All I Really Need to Know I Learned in Kindergarten to provide a useful framework5. Some aspects of the book really require no explanation (Wash your hands before you eat! Flush!), but for this article, we condensed Fulghum’s messages into five simple tips that might allow for improvements in our own quality of life by enhancing satisfaction in our workplace collaborations (Table i).


FIVE TIPS FOR ONCOLOGY WORKPLACE HARMONY The Importance of Sharing and Caring
From as early as we can remember, the importance of sharing was a lesson taught and reinforced daily.Share your blocks ... your crayons ... the swing at recess.Not sharing would result in punitive repercussions such as lectures from authority figures and perhaps the most dreaded consequence of all-a time out!Although sharing is a basic principle taught early on, the concept of sharing sometimes seems foreign in our present-day organizations.In the workplace, talking about "owning" or "delegating" is common practice.However, sharing and collaborating-although often "encouraged"-aren't truly championed and are rarely, if ever, enforced with any type of corrective repercussions.Working together as a team allows for idea-sharing, personal and group responsibility, and accountability.The process of collectively striving for a common solution helps to spread the workload evenly and enables employees to share in the successes and to learn from the failures together, ultimately cultivating stronger and more meaningful workplace relationships.
As a practical suggestion, if you see something-for example, a paper or a project-that might interest others, let them know about it.If they are interested, include them and share the success.Instead of asking yourself what you might have to lose by sharing, consider the situation and ask how much more you can actually gain.
In day-to-day interactions with others in the workplace, are you acting as a bridge or as a barrier to the success of others?Sadly, too many people act as barriers.For them, the answer to all questions is no.Are you one of them?Most people who act as barriers don't realize what they are doing or what message they are relaying to the workplace.Instead of being an obstacle, let being helpful be your default position.Make it a priority to nurture relationships.
Another aspect of sharing relates to workload distribution.Within an ideal group structure, it's essential for everyone to do a fair share of work and to pull their own respective weight.However, the more commonly demonstrated example is to see more work assigned to those who already do the most work, and less to those who don't!The result is increased risk of burnout on one side, promotion of disengagement on both sides, and ultimately less productivity overall.One person can't do everything.One practical example of structural organization in one of our institutions (MC's) has been the creation of a team workload allocation committee.The idea is meant to ensure that annual assessments do not force everyone in the department to practice in the same way, at full pace, and in all work elements (for example, billings, number of new patients seen, research, administration, and teaching).Instead, a balance is sought, matching the overall needs of the various divisions with the individual strengths found among colleagues.

Be Observant: Look, Listen, and Communicate
Communication is not just talking and listening; it is also understanding one another.Communication is a complex process that involves the sender, the message, the receiver, the situation (when, where, or how the communication occurs), and the feedback that one person receives as he or she talks and then listens to the other 6 .
Talking with one another is something that seems as if it should be really simple, but based on the enormous volume of resources available on the topic, skills such as listening are at the forefront of the skills that people need to learn how to perform well.Factors that can lead to communication misunderstandings are assumption, perception, inference, and projection.Sadly, most of the times that we have thought I made my intentions clear, or They should know what I meant, the sober fact is that we or they probably didn't.
In addition, we transmit significantly more information through nonverbal than through verbal communication 6 .In fact, the message received often has more to do with how something was said, rather what was actually said.Research shows that only a small percentage of our overall message comes from the words used-55% comes from body language (especially movements of the small muscles around the eyes, which can convey shock, disbelief, doubt, or disgust); 38% comes from tone of voice; and only 7% is conveyed by the actual words used 7 .Tone of voice alone can convey anger, frustration, disappointment, sarcasm, confidence, affection, or indifference.
To be able to communicate effectively (and accurately), the verbal and nonverbal messages have to be consistent.If the words conflict with the tone of voice or with the nonverbal behaviours (or both), the hearer often mistrusts the words and tends to believe the nonverbal clues instead.For example, it's not very convincing to be told that someone is not angry with you when the person doing the telling is avoiding eye contact, has an angry expression, can barely force out the words, and slams a fist on the table while saying "I'm not angry"!

Be Respectful: Say "Sorry" When You Hurt Someone
Treating your colleagues with respect is an obvious but often overlooked courtesy in the heat of the moment.Instead of condemning people, first try to understand their viewpoint and try to determine why they do what they do.Seeking understanding is a much better use of time and energy than outright blame and criticism; it breeds sympathy, tolerance, and kindness for others.Given immediate access to electronic communication and quick trigger fingers, we live in a time when negative comments are too easy to propagate.When hit with the immediate urge to reply (or even worse, "reply all"), stop.Allow for a cooling-off period.Ask yourself this: Will your reply do more long-term harm than good if you send the message?We have all been guilty of pressing Send too fast and putting perceived self-interest (usually ego) with respect to a particular issue above thoughts about the greater good.But even worse are the repeat offenders, always quick to press Reply All to express whatever their annoyance over a particular issue might be.We all know some of those people, and sadly, although we may roll our eyes when we receive their messages, those repeated nonfunctional behaviors rarely-if ever-result in a change for the better.Though we all inadvertently fall into such behaviours at various times, those colleagues in particular do not seem to realize the actual harm they are doing to themselves (in terms of reputation) and to the group as a whole.Remember that not every potential sensitive issue that confronts you by e-mail is an emergency.Rarely are such messages life-and-death matters.Try not to respond reflexively.Stop and allow time for thought.If after taking that short pause you still think it valuable to respond, try to provide feedback that is both constructive and meaningful.Do not just add more fuel to the perceived e-mail fire.This simple tip can save a lot of future hardship.
Although conflict avoidance is better than conflict resolution, working with others in any organization will eventually result in a conflict of opinions, which should not be seen as a negative.Without such challenges, little change or growth would take place.Conflict can be either constructive or destructive, with the former type always being preferable.For most of us, conflict brings negative associations and feelings, ineffective solutions, and unresolved issues to the surface.An oncologist's job is filled with interactions with other people, and although almost all such interactions go well, we are all aware that certain behaviours by ourselves or others can have a negative effect not only on other individuals, but also on entire groups of people.Bearing those potential influences in mind is important, because a significant proportion of our waking hours are spent with work colleagues.Physicians typically consider themselves to be highly educated and sensible members of society and therefore surely above involvement in the common quibbles of life.Such idealistic thinking ignores our own humanity and the petty jealousies that life can throw at us.The education and position in society that physicians hold should hopefully allow us to process our faults and to work more for the well-being of colleagues.
The conf lict model suggests that, as individuals, we formulate beliefs and attitudes about conflict from past experiences.For example, if an individual's attitude toward conflict is negative, and if their belief is that conf lict can be resolved only through zero-sum means, those perspectives will directly inf luence the choice of response, which will likely result in negative win-lose consequences that will in turn reinforce the original attitudes and beliefs.The overall relationships of participants in a conflict are very important to successful resolution, because conflicts rarely occur for one time only.For the most part, people are sincere in their behavior; unexplained motivations can lead to conflict.
As in all relationships in life, conflicts at work can reach a breaking point.Is it unreasonable to expect that someone would show you respect by listening to you?To respond without inflicting wounds on your feelings of self-worth?To treat you with common courtesy?Is it?We all have varying expectations, and we must accept that at times, those expectations will not be met.As we see it, there are three options in those situations: All of us tend to enjoy looking after cancer patientsbut is your practice becoming unmanageable?Are you on too many committees?Are you a "yes" person?Stop.Seek ways to get back on track.In an ideal world, such reflection would take place during an annual assessment-a time that, sadly, rarely provides sufficient space for such introspection.Most of us find that, as long as we are seeing enough patients, the assessment will go well, with little discussion about what we really want to do.
Remember that everyone has to do things that they don't want to do, but play is an important part of being happy-a sentiment that rings true for the classroom and for office spaces.In play, you can use your imagination, be creative, and have fun."Work hard, play hard" isn't just a catchy phrase people use-it works.Often, when workloads grow heavier, play is the first thing out the door.However, it's important to take a few minutes here and there throughout the day to do something that makes you happy.Those intervals of play might just be the times when the "aha" moment that you have been waiting for strikes.

Life Is Amazing: Be Aware of Wonder-It's Over Before You Know It
One of the main statements from Fulghum's book is "Look!"Never stop learning and looking 5 .Like the kindergarten of our childhood, our current work world provides endless opportunities.It is a space in which imagination, ingenuity, innovation, connection, and discovery collide, and play is the exultation of the possible.As practicing clinicians, we work in the most marvelous of ages-an age in which influence, power, and success will no longer be determined just by how hard we work, but also by how well we play together in our space.
Despite so much time spent in the pursuit of being "good physicians" (following up-to-date practice, completing seemingly endless streams of institution-mandated paperwork), we sadly spend relatively little time talking about what is really important in life: our interactions with one another.Have one another's back, and trust one another.
Trust is defined as a "state involving confident positive expectations about another's motives with respect to oneself in situations entailing risk" 8 .It is based on honesty, integrity, and genuine concern for others.Trust ranks among the very few resources in life that are increased rather than depleted through use.Be trustworthy.The five key ingredients needed to improve trustworthiness are to be predictable, be clear when making commitments, be honest, take promises seriously (be dependable and accountable), and model what you preach.

SUMMARY
As you read the five tenets presented here, think about these simple truths of leading and influencing others, managing failure, thinking strategically, and resolving conflicts.Apply them to the world in which we all now live and play.Far too often work (the place) is viewed simply as where work (the action) occurs.What we are saying is that, although institutional targets (such as reducing wait times to see new patients) are all laudable goals, there has to be more, and play has to become an essential component of work.What can we uncover, rediscover, and create to make the time spent with one another the best possible experience for everyone involved?Even more importantly, what must we do to ensure that what we create and share has the possibility and potential to make our lives and the world a better place?Play isn't something we do as a part of life-it is life.
FIVE TIPS FOR COLLABORATION IN ONCOLOGY, Arnaout et al.

TABLE I
5ips for enhancing satisfaction and collaboration in the workplace, as adapted from All I Really Need to Know I Learned in Kindergarten5When you go out into the world, watch out for traffic, hold hands, and stick together.Be observant.Look, listen, and communicate.Warm cookies and cold milk are good for you.Learn some and think some and draw and paint and sing and dance and play and work every day some.Remember the Dick-and-Jane books and the first words you learned-the biggest word of all-LOOK.Remember the little seed in the Styrofoam cup: the roots go down and the plant goes up and nobody really knows how or why, but we are all like that.
n Play fair.n Put things back where you found them.n Don't take things that aren't yours.n Clean up your own mess.n n n n Take a nap every afternoon.n Don't hit people.Be respectful of one another.n Say you're sorry when you hurt somebody.n n n Goldfish and hamsters and white mice and even the little seed in the Styrofoam cupthey all die.So do we.e439 Current Oncology, Vol. 24, No. 5, October 2017 © 2017 Multimed Inc.

Live a Balanced Life: Sing and Dance and Play and Work Every Day Personal
Try to explain what you need so that the individual you are addressing has the opportunity to listen, to know that they aren't meeting your needs, and to make an effort.n If the person cannot or will not meet your needs, you can either accept that fact and deal with it as best as possible, or move on.n Either way, don't beat your head against a wall.Just learn to let it go.Or to let them go! happiness makes for a more effective and collegial individual.Remember what makes you happy.At times, we all feel overwhelmed.Sadly, we are often not good at admitting it, frequently coming to such an admission far too late.At those times, we all need to stop and reflect: Why am I feeling like this?An evaluation of what you are doing and some reflection on what actually needs doing often helps 2 .