Working together in Rwanda
By Dr. Eric Walton
Forming. Storming. Norming. Performing. Those are the four phases of group development I was taught years ago when I first took on a leadership role in a service-based organization. It isn't a particularly difficult concept; many people intuitively observe this process when they embark on a new venture. Regardless, I find this simple framework incredibly helpful when I am thrust -- willingly or not -- into new experiences. In this case: traveling to a new country to work with new colleagues doing complex cases in an unfamiliar environment. All in one week. Easy.
Forming describes that awkward phase where we defined relationships and group roles. On the other side of Rwandan customs, I met our team members from the United States in-person for the first time. Everyone else had at least one other familiar face, so I certainly felt like the odd one out in the group. The next day we have clinic at the hospital, and I meet our local Rwandan team members; there are a couple local attending urologists and several residents. We immediately jump into clinic visits and establish for patients that our Rwandan team members are the lead physicians. We are there to provide guidance and advice. We clunkily work through the first few patients, and I gain confidence with my role: ask questions, provide recommendations, and perhaps most importantly slow things down to capture important details for our medical records.
Storming is the part where things don't run seamlessly while team members adjust to their roles. I know how to be a fellow. I know how to work with attendings in the operating room. I know how to teach residents. On our first day in the OR, I didn't really know how to do these things with the addition of a second attending who is also there to learn, in an unfamiliar environment, with less-than-ideal tools, while navigating a communication barrier with the resident. Nothing bad happens, of course. We are, after all, professionals. But I was definitely frustrated.
Once we established how to function as a team, we reached the norming phase. By the end of the first day, we've learned how to work together in Rwanda. There are countless takeaways from an experience like this, and everyone learns something different. Here are a few of mine:
1. Be flexible and creative. The scissors may be blunt, and I may not have the instrument I truly want, but there is enough equipment to get the job done safely.
2. Teaching time outs work. Take a moment at the start to outline learning objectives for each learner. This removes the ambiguity of what should happen and when.
3. Be patient. Even though we all spoke English, there were still communication barriers: accents, turns of phrase, rate of speech. Going into this experience, I knew these might be challenges but it's easy to forget them when my nervous system is working in overdrive. It became apparent to me early on that I needed to slow down my speech and use precise language.
The rest of the week, when we've learned how to work together efficiently as a team, is the performing phase. During that time, we tackled 15 complex reconstructive urology cases, essentially all for urethral stricture disease. And more importantly, we built capacity for GU reconstruction in Rwanda. Along the way I learned there are a lot more similarities than differences between our practices. Our hospitals may have different instrument trays, sterilization techniques, and patient populations, but we can treat complex urologic problems in both places. We experience the same frustrations (i.e., the light cord will never work properly the first time) and we all want the best outcomes, opportunities, and experiences for our patients. These lessons I brought home from Rwanda will make me a better surgeon and teacher. I am grateful to be part of this global health community, and I am excited for future opportunities to do this work in Rwanda and beyond.