This week’s Recast is from April 2020.

Why This Episode Matters Now:

In 2022, the war in Ukraine revealed something our partners had been experiencing but we hadn't fully articulated: the traditional model of intact, homogeneous teams wasn't sufficient for the emerging operational environment. Individuals with diverse expertise, geography, language, and allegiances needed to rapidly converge into what we call Tactical Swarms—heterogeneous cross-functional units that form, solve emergent problems, and disperse.

Our recent white paper, The Fourth Generation of Military Special Operations Selection & Assessment, explores this evolution in depth. But six years ago, Preston laid the foundational concepts in this conversation with Coleman.

What the Research Shows:

Many operators who excelled at teamwork—performing with known, homogeneous teams—struggled with teaming: the ability to rapidly build cohesion within heterogeneous groups. This episode examines why routine versus critical communication and field observations across special operations, emergency medicine, and other high-stakes environments. In this episode, Preston and Coleman describe how tactical swarms and X teams differ from traditional team structures, and they distinguish between routine and critical communication and when teams must shift between them.

Recent Research:

1. Cline, P.B. (2026). The Fourth Generation of Military Special Operations Selection Assessment: A Community of Praxis [White paper]. Mission Critical Team Institute. DOI 10.13140/RG.2.2.28255.73121. https://missioncti.com/wp-content/uploads/2026/02/The-Fourth-Generation-of-Military-Special-Operations-Selection-Assessment_Final_2-Feb-26.pdf
2. Falk, D., Cline, P., Donegan, D., & Mehta, S. (2023). A Novel Framework for Routine Versus Critical Communication in Surgical Education—Don’t Take It Personally. Journal of the American Academy of Orthopaedic Surgeons, 31(3), 115–121. https://doi.org/10.5435/JAAOS-D-22-00912 https://missioncti.com/wp-content/uploads/2023/08/FINAL-A-Novel-Framework-for-Routine-Versus-Critical.pdf

If you find value in this discussion, the best way to support our work and stay up to date on future episodes is to subscribe and leave us a quick rating or review. It helps us reach more people who need to hear these conversations.

This episode contains a term that may be offensive; it is used to describe gendered communication dynamics. We have included it to accurately represent the event, and it is intended for educational purposes only.

Welcome to the Teamcast.

2

I'm Dr.

3

Preston Cline, director of the

Mission Critical Team Institute.

4

Here we discuss all things

mission critical teams.

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These are teams of four to 12 people,

indigenously, trained and educated, who

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solve rapidly emerging complex adaptive

problem sets where the consequence of

7

failure is death or catastrophic loss.

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With my colleagues and our guests,

we bring you insights from combat

9

zones to emergency rooms dedicated to

improving the success, survivability,

10

and sustainability of these teams.

11

We grab.

12

With how to prepare for future

events and how to develop language

13

and frameworks to transfer critical

off and unspoken knowledge.

14

Whether you're on a mission critical

team or not, we aim to bring you

15

the broadest range of topics and

guests as possible to help prepare

16

you to perform when it matters most.

17

Thank you for joining us and

hope you enjoy the Teamcast

18

Welcome back to the Teamcast.

19

I'm Coleman Ruez.

20

Today's topic is routine versus critical

communications and why it matters to

21

certain types of teams, which Preston

will talk about here in a second.

22

Teams called swarms.

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Teams called X-Teams and why

that's relevant today and why

24

it's frankly relevant every day.

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So as we get started, Preston,

can we back up for a second for

26

the audience and just go all the

way down to the weeds and define a

27

mission critical team for everybody?

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Preston: Thanks, Coleman, very much.

29

Mission critical teams...When

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I first started doing my doctoral

research, one of the things that

31

I wanted to be really clear about

is, is what kind of team they are.

32

There's a bunch of researchers out

there, including Hall, that have

33

done sort of taxonomies of teams

and there's o over in the academic

34

literature, there's over 50 or 60 or

a hundred different kinds of games.

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Negotiation teams, trauma teams,

special operations teams, and I wanted

36

to be clear that the teams that I

was looking at were very specific.

37

They weren't for everybody.

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And a big reason for this is because

at the time I was working at the

39

Wharton School in the leadership

program there, and the Wharton School

40

and business schools and academia

have a long history in decision

41

sciences and studying decision theory.

42

90% of that, including Kahneman and oh

many, many others, when they talk about

43

decision making, they're talking about

decision making in an a temporally,

44

unconstrained environment, which is to

say we might make a decision tomorrow,

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next week, next month, next year.

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The teams that I was looking

at, that wasn't the case.

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They were making decisions

in half a second in seconds.

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And so when we first started coming up

with, and I first started looking at

49

these definitions, I wanted to be sort

of clear in my definition to characterize

50

what was saying, what was different.

51

So it starts off that mission

critical teams are defined as small

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group dynamics, four to 12 people.

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And the reason that matters is that small

group theory states that, you know, if

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you're at a cocktail party and you're

gathering with a group of people and

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it gets to say into that circle of nine

or 10 people, it starts to split off.

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It's a natural human condition,

and that's why teams in the

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military and law enforcement,

they tend to stay in four to 12.

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Underneath that is a triad or a couple

or a singleton, and those aren't teams.

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Secondly, you need to know

that a team is not a group.

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A team is by definition interdependent.

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You and I aren't on a team

unless I need you to do your

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work so I can do my work, right?

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That's the difference

between a team and a group.

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And so when I say mission critical

teams, you know, part of it is

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that they're integrated groups of

indigenously, trained and educated.

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And so again, into the weeds, indigenously

means that you don't go to college

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to go to the FDNY, you don't go to

college to go to the Navy Seals.

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You don't go to college

even to be a trauma surgeon.

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You go to college or not, but you're

going to that organization and the

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senior gray beards or blue hairs, as

we say, the elders in that community

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are the ones that determine whether or

not you're gonna make it onto the team.

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What we call the cadre, the instructor

cadre of the, the communitas, as we would

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say, or the collection of individuals

that have been through the experience

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that you're now going through, they're

the ones who can make it sacred, who can

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actually confirm that you're entering

into their world, their communitas.

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That's what I mean by

indigenously trained and educated.

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Trained and educated.

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I mean by training is for certainty.

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Education is for uncertainty.

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We train people for skills.

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We educate people for thinking.

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We train people for reactions.

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We educate people for response.

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In our world, we train people how

to use a gun, but we educate them on

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when, where, and why you'd use a gun.

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And those are actually different things.

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Your brain learns differently on

how to use your hand or how to

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ride a bike than it does, how to do

calculus or how to predict the future.

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Not that we'd ever, are we good

predict predicting the future.

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Then these teams are focused on resolving

rapidly emergent, complex adaptive

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problem sets, and it'll be another time

where we talk about problem sets and

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the theory surrounding them, but just

know this, the only reason all these

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mission critical teams exist is because.

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The conventional solutions in the

hospitals and the military and law

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enforcement encountered a problem

in the fifties, sixties, and

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seventies, which their conventional

tools could no longer solve.

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And so they had to create these teams.

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They had to create seals and SWAT teams

and trauma surgeons, and in command teams.

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They were necessary because the

problem sets that were emerging in the

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world required that kind of agility

that a conventional organization

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just can't do because they need more

predictability than they need agility.

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And as we've talked about in the past,

when you choose predictability, you

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trade agility, and when you choose

agility, you trade predictability.

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And then these folks work in what we

call immersive but constrained five

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minutes or 300 seconds or less temporal

environments where the consequence of

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failure is death or catastrophic loss.

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So the death or catastrophic loss, sort

of self-explanatory, but let me do the

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immersive and 300 seconds immersive is

for those of you who live in this world.

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And this is also true by the

way of professional sports.

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It's true of giving birth.

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It's true of a variety of things,

but the truth is that the easiest

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way to understand this is through

the lens of a firefighter.

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If I'm standing in front of your house and

it's a normal day, I can walk in and outta

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your house and my reality stays the same.

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If that house catches fire and I walk

into that same house through that same

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threshold, I walk into a different

reality, a different space and time.

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Space moves differently,

time moves differently.

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It's called an immersion event,

and you enter into it and you

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have to exit out the other side.

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You can't stay there, you can't

turn around, you can't press pause.

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It is what it is.

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A firefight.

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A heart surgery.

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You can't say, you know

what, I'm feeling tired.

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I'm gonna take a nap

and come back to this.

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Nope.

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You're immersed into it like

swimming to the bottom of a pool.

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You can't pause.

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You gotta keep going and come back

'cause the air is above the surface and

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the last thing is 300 seconds or less.

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Why 300 seconds?

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Roughly speaking.

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That's about how much oxygen you

have stored in your brain right now.

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So you've got about 300 seconds

of oxygen stored in your brain.

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So if your throat got closed,

right, so you couldn't breathe.

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We'd have to solve that problem in

300 seconds or less, or we'll start

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to see cellular death in the brain.

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A lot of things can be fixed

in 300 seconds and there's

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more time than you think.

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In 300 seconds, do yourself a little

favor and start playing around with that.

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Just do the simple tasks around

your house and time them.

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How long does one minute really last?

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And then think about sort of a

chaotic moment and think about

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how long does a minute last.

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And this, this actually matters

and it's a good habit to know.

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One of the universal things, which

I'll close out on this is that no

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matter how experienced a firefighter

or a trauma surgeon or a special

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operations personnel that I work

with is none of them can accurately

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tell time in an immersion event.

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Michelle Fitzsimmons, the well-

known captain from the FDNY, who

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is a good friend of mine, she's

actually developed a habit where.

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She knows how long, roughly, she's

figured out how long it takes for the

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water to reach the bottom in her boots.

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She knows how long it takes to stretch

a hose from the hallway to the room,

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and literally that's how she tells time,

not by telling time, but there's certain

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markers in the event where because she's

wearing oxygen and they only have 20

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minutes of oxygen, she needs to have a

rough indication of where her and her

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team are in terms of oxygen consumption.

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She's worked out these little cues

to tell her, okay, we're a, we're

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midway through, we're halfway through.

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We're a third of the way through, and

that lets her know how to do cadence.

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That's the definition as I use it, of

mission critical teams as we use it.

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Coleman: The thing that gets me excited

about any team that has this fluctuation

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between routine and critical, which

obviously we're gonna talk about

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today as the primary topic routine

and critical communication, is that

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we can take someone from the outside,

let's say, who was criticizing the

167

definition, quote unquote, let's say,

well, a firefighter's not always making

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a decision in 300 seconds or less.

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That's That's absolutely true.

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Yep.

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A hockey team or a soccer team,

or a football team, neither is

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a trauma surgeon, neither is a

soldier, but the type of team.

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That is four to 12 in size.

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That works in a rapidly emergent, complex

environment that does have times in their

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job where they have immersion events.

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Those events where once you start

you can't reverse and you definitely

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don't wanna stay there forever.

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Preston: Right.

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Coleman: Football player with a

football isn't running forever.

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Like they're gonna reach

the end zone eventually.

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Right.

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All those conditions exist for.

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More teams than I think we

would intuitively believe, you

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know, have those situations.

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Now obviously we work with a pretty

narrow set, but people can adapt that

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idea to almost anything in their life.

187

If you have moments where you know

you're in an immersion event and you're

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making a decision in 300 seconds or

less, just take into consideration

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some of the topics that are relevant.

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Preston: If you think about the Navy

seals, if you think about BUDS and

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basic underwater demolition school,

it's a very storied celebrated and

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well-documented process that you've,

you instructed in front of, and there's

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a, there are dual processes going on.

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The selection of a candidate in BUDS.

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One is there is a Navy process.

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There are tests and scores and

predictive analytics, and there's a

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bunch of things that are necessary

so we don't hurt people, right?

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And, and we've learned over the years

there are certain rules involved,

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and those rules need to be upheld and

measured and tested in quantitative ways.

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We need to put numbers.

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To paper.

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There are other things though, Coleman,

that are key to becoming a Navy SEAL

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that you're never gonna measure.

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And I'll give you an example.

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Sense of humor is something that

is reported by all the teams

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that we study around the world.

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Rate of learning.

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Those are the kinds of things

you can't actually measure,

209

you can't put a number to.

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I know there's gonna be some people in

the audience that say, well, Preston,

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we actually can measure cohesion.

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We can measure.

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And I'm like, not really.

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I mean, let's be honest.

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I, I think you're, you're doing your best.

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But at the end of the day, we can't tell

the weather out seven days ahead of, we

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can't measure it's human beings for sure.

218

We're incredibly complex individuals

put us in a group and the

219

complexity goes off the charts.

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And so.

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I would just say that, that we

should recognize whether you

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agree with the particulars or not.

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There's a number of things that

are key to being a member of any

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tribe, a member of any community.

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There are certain things we cannot

measure, but are critical, and

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these are qualitative things, so

the cadre, the, the Navy SEALs

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who are running BUDS as you did.

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And I wanna get your

thoughts on this in a second.

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You have your own criteria,

your own qualitative, tacit,

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and remember, tacit knowledge.

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We know how to ride a bike, but we

can't explain how to ride a bike.

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You after many years, and the seals

know what a good seal was, is, but

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you may not be able to articulate it.

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Collectively, you share that belief

system and that unstated tacit knowledge,

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that shared belief of what right

looks like and what wrong looks like.

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This is the sort of tacit knowledge

that is held by what anthropologist

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Victor Turner called the communitas.

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This is the elders of a tribe who

know the truths of a tribe, who aren't

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able to articulate it, document it or

quantitate it, quantify it, excuse me.

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This is as important as the quantitative

information, and this is the key point.

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They're both important, but they're

valid for different reasons.

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They use different methodologies, they

use different language, and some of

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it is really difficult to articulate,

but it doesn't make it any less true

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in the same way that I love my wife

more than anything else in the world.

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Could I explain that to you?

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No, but it's true.

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And so my habit now is just

to introduce love at every

248

one of our Teamcasts, Coleman.

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Coleman: I love it.

250

Thanks for doing the explanation.

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It's amazing when we have group courses

or interactions every time that we

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present on community versus communitas.

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There's some head nodding up and down.

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There's some kill face.

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There's some eyebrows that go vertical.

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Preston: Yep.

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Coleman: It's typically.

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It's a phenomenal conversation

with whatever team that we're with.

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Yeah.

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Because I think if any of us just slow

down for one second and realize how

261

empowering and exciting it is on a team.

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Preston: Yep.

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Coleman: When you have this communitas

and paradoxically, when I was an

264

instructor and started thinking about

this more, it's the thing that scared

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me the most because what I thought was

a good troop commander graduating from

266

our advanced training school could be,

probably not completely different, but

267

potentially meaningfully different in

terms of communitas from the next person.

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And if the structure of the organization

take an athletic team, for example,

269

the communitas rides on the shoulders

of the coach, the staff, the energy

270

in the locker room, depending

on what the leadership is like.

271

Preston: And you know, one of the

things that we've been brought in

272

from time to time, unfortunately,

is when a team goes sideways, that

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will happen at the edge of things.

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These teams are at the edge of things

and , they have high autonomy and

275

sometimes the community, for whatever

reason, there's a bad actor, there's

276

been some bad experiences, there's been

some festering infections socially and

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they don't get addressed, and all of

a sudden that communitas goes dark.

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And unfortunately there's not

a lot of easy fixes for that.

279

That's a bad, bad day, and that's why

it's so critically important that the sled

280

dogs, the members of the communitas, hold

each other accountable every day because

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the consequence of them going sideways.

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We need them to be highly adaptable,

highly fluid, highly autonomous.

283

And the cost of that is that they

also have to have high integrity.

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And if they don't, oh gosh, it goes bad.

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Bad.

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Coleman: I wanna make one more

comment on this and then we're

287

gonna shift to the key topic.

288

All the great leaders I've ever been

around, they don't always start their

289

opening conversation with a new team,

but you would hear often from them

290

that the only wrong answer is that's

the way we've always done it before.

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Preston: Yeah.

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Coleman: Everybody's heard that

at some point in their lives from

293

somebody like this, this is it.

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Why do we do it like this?

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Well, we do it like this 'cause this

is the way we've always done it.

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But if we had the opportunity to

ask the follow on question, well,

297

what's the way we've always done it?

298

You ask the other 30 people on that

team in separate rooms, like almost

299

like a prisoner's dilemma thing?

300

Yeah.

301

If you don't get the same answer from

every single person individually,

302

you know that you have a misalignment

potentially in communitas, right?

303

The way things used to be is

naturally it's individual and that

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great teams don't operate that way.

305

They eventually take the

time, the energy, the effort.

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To put a shared language to the communitas

portion of what we do, and as painful as

307

that can be sometimes as the community

knows, especially 'cause of Coronavirus

308

and a bunch of our teammates who are

frontline healthcare responders and

309

doctors, we've just been over energized

with concluding some ongoing research and

310

collaborations, and it's why we started

the podcast is so we could continue to

311

export some of the things we're seeing

across the entire MCTI community.

312

And one of those topics is this

idea of X teams, swarms, different

313

types of teams that have to come

together, that want to come together

314

and the way they communicate.

315

And their communication stove pipes

in a way can be separated in two

316

broad categories, routine situations

and critical situations that require

317

different shifts in our communication

styles, particularly with teams

318

that are just coming together and

have people that they don't even

319

really know each other that well.

320

So let's shift gears into that,

Preston, and get your background,

321

your experience, and some reflections

on, on this recent paper we put out..

322

Sure.

323

So about a year

324

Preston: ago, a little over a year

ago with our friends and partners at

325

Arena Labs, Brian Ferguson and Dr.

326

Doug Johnson, we wanted to look at this

question of very specific question,

327

which was, in certain certain hospitals,

in certain surgical units, there's

328

a number of actors that need to come

together for surgery to be successful.

329

You obviously have the surgeon.

330

You also have a number of other roles

in that room, the anesthesiologist,

331

the scrub nurse, and the

circulating nurse among others.

332

But we're gonna focus on, on those roles.

333

One of the problems that's happening

right now nationwide, before COVID

334

was the medical system in the

country is under a great deal of

335

strain and isn't really function.

336

It's really designed to do the things

we're we're currently asking it to do.

337

And we're seeing a lot of friction points.

338

And one of the challenges is, is

that you need to go through certain

339

roles and sequence in order for you

to get to some of these key roles.

340

So for example, in surgery, it is

common for you to start as a circulating

341

nurse before you become a scrub nurse.

342

That is the nurse that

assists the surgeon.

343

We say a scrub nurse and circulating

nurse, and you probably might envision

344

the historical roles these nurses

play that you've seen in movies.

345

And what I wanna be really clear

about here is that these are highly

346

trained, really sophisticated.

347

Skills and talented individuals,

these aren't people that show up

348

that morning and learn this craft.

349

It takes years to learn it.

350

One of the problems is, is that

they need people to come in to be a

351

circulating nurse for a little while

before they become a scrub nurse.

352

And what some hospitals are seeing

is a high attrition in circulating

353

nurses, meaning they're coming in.

354

They're staying for a little

while and they're leaving and they

355

no longer make it the graduate

to the scrub nurse downstream.

356

This has huge negative implications.

357

And so at the time, pre COVID, we were

trying to figure out what was causing

358

this high attrition for circulating

nurses, and there are a number of

359

variables in play here, but we were

focusing on one specific one, and the

360

premise was pretty straightforward.

361

The belief at the time

was doctors are jerks.

362

And this has been reinforced by a

number of people, including doctors and

363

nurses, that there's some truth to this.

364

And the belief was is that doctors, for

a variety of reasons, lack a certain

365

amount of empathy, and in that lack

of empathy are rude and obnoxious and

366

critical of nurses and drive them out.

367

This was the assumption, right?

368

And so I had been asked to walk

into this particular hospital and

369

observe three surgeries in a row,

happened to be heart surgeries.

370

And the heart surgery,

it lasts for three hours.

371

And this is important, and I'm gonna try

to describe this to you over the radio

372

in a way that you both understand the

theory, that it underpins it, but also

373

the actual lived experience of that event.

374

So the first thing you need to know,

theoretically, is that heart surgeons

375

specifically are hybrid teams.

376

And here's what I mean by that.

377

They're typically intact teams,

meaning that they're the same

378

people that work together.

379

Day in, day out.

380

So they get to know each other,

build trust and cohesion.

381

The second thing you know, the reason we

call them hybrid teams is because if, for

382

example, on average heart surgery lasts

three hours, that roughly the first hour

383

is a routine surgical event, which is

to say, we're kind of making the donuts.

384

Everything is gonna be done

by a checklist as a tool.

385

Gawande talks about in his research, and

I recommend his research, is he got great

386

books and the first hour is routine.

387

You know, you, you're gonna clean

them up, you're gonna, you're gonna.

388

Get all the stuff sorted out.

389

Everybody's gonna do the things and

the, and you're having this normal

390

kind of a conversation, and then an

hour in, you're gonna switch that

391

person over onto the heart lung

machine to keep them alive while

392

you're messing around with their heart.

393

That's my technical term, messing around.

394

What will happen though, is once

you turn on that heart lung machine,

395

you have a statistical time limit

before the likelihood of that person

396

getting a blood clot in their brain

because of the heart lung machine

397

goes very high, like scary high.

398

So you're gonna open up the chest on that

mark when you cross 'em over and you're

399

gonna turn on the heart lung machine.

400

And then basically you have

say 45 minutes to an hour to

401

solve whatever problems show up.

402

So whether or not you didn't see

something on the scans, whether or

403

not a mistake is made, it all has to

get solved at 45 minutes to an hour.

404

And so what ends up happening is

you move from this checklist driven,

405

conventionally minded routine surgery

into what is more akin to trauma surgery.

406

Yes, there's checklists.

407

Yes, all that stuff is still true,

but there's also high agility,

408

high innovation, high adaptability.

409

And then once you put them back on

the heart and get the heart restarted,

410

you go into closing procedures

and you're back up into routine.

411

So the final hour is routine.

412

So imagine that you have a team,

an intact team that is going from

413

routine to critical, back to routine.

414

Stop, pause, take a break, go

routine, critical, back up to routine,

415

pause, wrap, and then do it all over

again three times during that day.

416

You should know that in a hospital

you have typically personalities that

417

will gravitate towards trauma because

they like the critical environment.

418

And you have people that will gravitate

towards traditional surgery or

419

wards because they like the routine.

420

It's very actually hard to find people

that can do both and do both well.

421

And so they're an interesting team for

a person like us to examine because they

422

demonstrate skills and abilities that

are often not seen in the same team.

423

So in this particular case, I'm there

because I'm sitting in the room and

424

my job is to observe the behavior,

the communication amongst the team

425

to see where we can do a better job.

426

Teaching doctors empathy, and

that's the idea behind it.

427

Where are some inroads that we can

make with doctors to give them better

428

sensibilities around empathy and, you

know, good on them because it was the

429

doctors that actually asked for this, and

they were the ones that recognized they

430

could be doing a better job at the time.

431

That was the assumption.

432

And there's some caveats here.

433

I'm not making blanket statements,

just this particular phenomenon.

434

So I sit there and, and in the first

hour, the first three hours, the

435

first surgery, you hear things like,

I love you and thank you, and you're

436

awesome, and oh, we're excited to see

you, and you're doing a great job.

437

It was one of the most inclusive

and supportive working environments

438

that I'd seen in a long time.

439

It wasn't the team room

in special operations.

440

Coleman: I never heard those things.

441

Preston: Yeah, exactly.

442

And so this was this, I was sort of,

my head was scratching, like, I'm not

443

tracking, are they performing for me?

444

What is happening right now?

445

Just let me paint the picture of the

environment that we're looking at

446

in these kind of surgical events.

447

You're looking at a room and

I'll try to describe it to you.

448

It's the room, maybe the size of a

classroom, maybe a little bit smaller than

449

the classroom that you went to school.

450

The center of the room is empty,

but on the ceiling hanging from the

451

ceiling is a series of monitors all

angled in a sort of 360 kind of.

452

A situation that would basically sit

above where they're gonna roll the

453

patient into, they roll the patient into

the center of a room where there is a

454

big circle that's painted on the ground,

and we're gonna call that the bubble.

455

Okay.

456

The patient gets wheeled into

the bubble and then the sort of.

457

Technical ecology, the ecosystem,

the technical ecosystem,

458

it's built around them.

459

First comes the surgeon who

says, hi, my name is so and so.

460

You're here to get heart surgery.

461

Do you want that?

462

Or Are you here for an appendix?

463

And that gives them an

opportunity to go, no, no, no.

464

I just sprained my leg.

465

I don't need open heart surgery.

466

That doesn't happen, really.

467

And so they say, yep, that's me.

468

And they said, great.

469

And then we're gonna introduce

you to the anesthesiologist.

470

The anesthesiologist then rolls in

all their equipment around the head.

471

Proceeds to put the person under,

and then the rest of the technical

472

ecosystem gets literally rolled into

and around the patient and they build

473

this sort of technical ecosystem

or this bubble around the patient.

474

So you have the room, and the room

is managed by the circulating nurse.

475

Nobody gets in or outta the room.

476

That's a circulating nurse managing that.

477

Then inside the bubble you have the

scrub nurse and that nurse, male

478

or female is standing on a platform

that gets wheeled over the patient.

479

So they're a good head or shoulders

above everybody else, and that

480

way they can own the bubble.

481

So the scrub nurse owns the bubble,

the circulating nurse owns the room,

482

and they interact with each other.

483

That's how I saw it.

484

Probably surgeons might be more

specific than I am, but I'm

485

trying to tell a story here.

486

And so I'm watching all this

happen, and it's amazing, actually.

487

It's extraordinary.

488

And then you gotta remember that even

though I've been doing this for a long,

489

long time, I'm still a human being.

490

I'm 50 years old and I'm in the

corner trying to stay outta the way.

491

And I've been in many team rooms

around the world looking at elite

492

teams, and I pride myself on

staying outta the way of shutting

493

up, of not interrupting their work.

494

I'm there to observe and not

to intrude, not to be noticed.

495

So in between the first patient and the

second patient, some of the, the medical

496

personnel in the room and in the hospital

heard I was in the building and wanted

497

to ask me on a break about my research,

what I was finding, why I was there, all

498

that sort of stuff they had heard about.

499

And I was like, yeah, sure, of

course I'm a guest in your house.

500

So they're asking me these questions

and I'm answering it because I'm old

501

and there's all this ambient noise.

502

I'm speaking loud like I am right now.

503

Right?

504

Like Coleman and I get

feedback on, I speak too loud.

505

In that moment, the anesthesiologist

steps out from behind the patient who

506

is the second patient who is putting

under to have open heart surgery.

507

This person's probably terrified and

says in the nicest, kindest way, Hey,

508

Preston, can you and he, and he puts

his hand out, like to turn a dial and

509

he says, Hey, Preston, can you dial

your voice down just a little bit?

510

I'm still putting the patient down.

511

Now if I was him, Coleman, I gotta be

honest with you, I would've just thrown

512

me outta the room like I would've chewed

me out and thrown me outta the room

513

like, this is open heart surgery chump.

514

Like this is not a time for you

to be having cocktail hour talk.

515

But here's the thing, Coleman,

as I mentioned before, I have

516

pride in my practice and I've

been doing it for a long time.

517

My inner monologue at that moment right,

is the toilet bowl spiral of death, of

518

shame and embarrassment and recrimination.

519

I am upset at myself.

520

My wife should leave me.

521

I should just be homeless.

522

I have failed.

523

Everyone failed him.

524

I failed the, my hosts, I failed

the patient who I don't even know.

525

And then also there's the

12-year-old boy in me like.

526

Hey, who's that doctor?

527

What, how are you talking to me like that?

528

And then there's my grandmother's voice,

like, how dare you insult a doctor, right?

529

And then I'm like, I'm sorry.

530

You know, to my grandmother,

all of this is happening in my

531

head in 15 in seconds, right?

532

It's just a crushing weight of despair.

533

And then of course, the

grownup in me is like, whoa.

534

Press and press and pressing press.

535

He, he's probably already

forgotten about it, right?

536

You have a thick skin,

he's gonna get over it.

537

If he really wanted to throw

you outta the room, he would've,

538

no one's in the wrong here.

539

Get it together and fix it.

540

And I was like, okay, thick skin, right?

541

And then I have this moment, this

sort of epiphany, and I go, hold on.

542

I'm here studying doctors, because

our belief is they're transmitting

543

in a way that lacks empathy.

544

But that doctor, that anesthesiologist,

just gave me feedback in the

545

most empathetic way possible.

546

And it was all about how I received

the information, not how it was

547

transmitted, how I received it.

548

I'm trained to receive feedback from some

of the meanest people in the world, right?

549

Like the harshest people in the world.

550

I can take feedback regularly,

like, thank you very much.

551

Write that down and take a look at

it without getting my feelings hurt.

552

So what just happened and how,

what do I mean by thick skin?

553

And so my brain gets to be like a

hamster on a wheel when this happens,

554

when I discover some phenomenon,

I can't explain for myself that

555

I have no framework to explain.

556

And so then I become this creepy

observer and I start looking at the micro

557

expressions of all of the nurses and the

staff in the room for the next six hours.

558

And here's what I find when a surgeon is

using a tool and they ask their nurse for

559

a tool or another tool, and let's say,

because it's very subtle, these stuff,

560

it's, it's very precise, it's very subtle.

561

And they say, Hey, I need this tool.

562

Or, Hey, no, not that one.

563

The other one.

564

Well, if you have pride and you work

and you think you're good at it,

565

that can be really startling for you.

566

'cause you like to pride yourself.

567

Like I should have given him

the right one to begin with.

568

He shouldn't have to

tell me the other one.

569

And so, how do we manage this

feedback, which we think, you

570

know, we're feeling emotionally,

but it's not emotionally charged.

571

It's not intended to be emotional,

and yet we're receiving that.

572

So I started, when I left there, I

was obsessed by this concept and I

573

started reaching out to some of the

like most thick skinned, roughest,

574

harshest people I know and go,

how did you learn your thick skin?

575

And they were like, yeah, I got beat up.

576

Like a lot and people just

told me, I gotta get over it.

577

Don't take it personally.

578

All these things.

579

And some of it, honestly, you know,

people don't like to talk about the toxic

580

masculinity stuff because people, it's

like a trigger word for people these

581

days, but there's some trick to it.

582

There's some stuff in male and female

culture both that isn't helpful.

583

Right?

584

And some of that is about how

we learn to take feedback.

585

And so we came up with this idea,

which is what if we, what if we

586

actually were intentional about it?

587

What if we took some people.

588

Before they were ever entering into

this world and explain to them using a

589

model very, very briefly, here's what

routine communication sounds like.

590

Respectful, courteous, kind.

591

Right?

592

We all agree on that.

593

And, and in a 302nd environment

where the consequence could

594

be death, you's what Critical.

595

You know, if your child is hurt, you don't

want people asking you a lot of details.

596

You want people to be direct,

monotone, factual, and fast, right?

597

Let's get this fricking thing done.

598

If you walk into a room and this is

the aha moment and you don't know me,

599

and I see a threat you can't see, and I

turn to you and I start speaking to you

600

in a critical communication framework.

601

I sound like a jerk.

602

I sound mean, I sound insensitive.

603

But the truth is, I'm

trying to keep people alive.

604

I don't see you.

605

I see you as a role.

606

I see you as a means

to keep somebody alive.

607

I don't see you as a human.

608

And when we started saying that to people,

to new staff, a lot of them were like, oh.

609

Oh, they're not mad at me.

610

They're not even mad.

611

They're not even talking to me.

612

They're just talking to the

person in my role, and they

613

need a thing from that person.

614

And they didn't, it

wasn't the right thing.

615

They just need the other thing.

616

That's it.

617

That's all of it.

618

And I'm like, yep.

619

And so, one last thing on this

because it's really interesting and

620

it's something I learned at Wharton.

621

This is not in the paper.

622

So at Wharton we went through a

period where I had 30, what are

623

called venture fellows, which are

second year MBA students who helped

624

me lead expeditions around the world.

625

And one of the questions that was asked of

us was, how do we develop female leaders?

626

And the first thing I was

like, well, I don't know.

627

I'm a guy so I know I'm already gonna

suck at that, but I want to be better.

628

I definitely want to be better

and I want for young women to be

629

better having spent time with me.

630

So what don't I know?

631

What can't I see?

632

And they, they did a skit for me

and it was like, it's never left me.

633

And they called it the red

pants skit, and here it is.

634

They put a bunch of dudes, a bunch

of guys on stage, and they had a guy

635

walk in wearing red pants and all

the guys were like nice red pants.

636

And then they asked the

audience, what did the guys mean?

637

And everybody was like, they

were making fun of his red pants.

638

Everybody was clear on that.

639

So then they kept all the guys on

the stage and they put all the women

640

on the stage and they had a woman

walk in with red pants and they had

641

all the women say nice red pants.

642

We asked people what they meant

and all the guys were like, well,

643

they were complimenting the pants.

644

And what the women explained to

us was they meant everything from.

645

Those are really nice pants to, you're

a slut to, I think you look fat.

646

All of us guys were like, whoa.

647

That's all in the nuance.

648

And they're like, that's our

lived experience every day.

649

So that gender dynamic, which I'm

sure I'm destroying somehow and

650

someone will correct me, but it was

this huge awareness for me that there

651

were colors of the rainbow I was not

seeing in day-to-day communications

652

that I just as a guy was not aware of.

653

And so when you look at their very

real gender dynamics in hospitals, for

654

example, this is one of the things in

critical and routine conversations that

655

needs to get addressed and needs to get

addressed by people smarter than I am.

656

But what we can do is amplify that.

657

It's a thing and we need

to get better at it.

658

Coleman: So thank you for that.

659

First of all, Preston, second of

all, you and I are not qualified too.

660

Make any comments on gender

dynamics, communication styles.

661

That's right.

662

But it just made me think what we

should do for the community is bring

663

a Michelle Fitzsimmons or somebody

from our community, Holly Ridings as

664

a guest, just to continue this thread.

665

Yeah.

666

You know, in terms of routine

and critical communication.

667

I just wanted to add one note as an

amplification, because if you really

668

slow down and think about this concept

in your own life, it's easy to pick

669

out places where you saw somebody

go from routine to critical and

670

you sort of took it the wrong way.

671

Right?

672

Or I know there's thousands of

places that I went to critical,

673

either too fast or intentionally,

and it wasn't set up properly.

674

So I have this memory hit me.

675

Years ago when we were co-teaching a

course at the graduate school there.

676

And when we were on this topic, my

first platoon commander at Seal Team

677

three, he passed away from complications

around a brain tumor that he got

678

later when we were in the teams.

679

But a fantastic guy.

680

And I remember when I was brand new at

the team, you know, contrary to people

681

who are outside the military who may

not realize, you know, contrary to

682

popular belief, it isn't this super

rigid chain of command, and particularly

683

in a special operations platoon.

684

And there's a lot of

flattening of the team.

685

People who are very junior get

a significant amount of input,

686

certainly compared to what you

see just in a regular business.

687

Very junior.

688

You know, folks in a special operations

team have a lot of say, and so we were

689

going through this training cycle for a

couple of weeks before going on deployment

690

and as platoon commander of ours.

691

He had a really good style, like

always taking input, always taking

692

input, always taking input and

applying it where he could and taking

693

everybody's notes and suggestions.

694

And there was one training trip

we were on, and I remember at

695

the time very uncharacteristic

of him, but he kind of like.

696

Cut everybody off, made

a series of decisions.

697

We went into this field training

exercise that we call FTX.

698

It didn't take two hours for a

little bit of rumbling in the platoon

699

to start like, what the heck is

wrong with, you know, so-and-so?

700

What the heck is wrong with so-and-so?

701

And he obviously picked up on it.

702

He wasn't stupid.

703

Later, three days later, when this FTX is

over, and this was one of my first, what

704

I consider not the garbage you list, you

learn in like leadership 1 0 1 courses.

705

My first real tactical lesson of

blending the art and science of, you

706

know, of leadership just in general.

707

He sat the whole platoon down and he

said, look, someday you're gonna be

708

a boss of something and you're gonna

have a thousand things pulling on you

709

to include temporal constraints, right?

710

Just pure time constraints.

711

I've tried to do a great job of taking

everybody's input when I have the time

712

and as much as possible, but there are

periods of time and most of the time it's

713

gonna be when we're compressed for time,

I'm gonna make a decision fast and quick

714

and I need you just to listen and do.

715

Right, and what he was saying, Preston

obviously was he was seeing a thing or

716

dealing with a thing or had some sort of

context that the rest of us didn't have.

717

And what I've since learned is the one

thing missing in that, that I think

718

is a freaking superpower of great

teams is the rest of us didn't know.

719

When he was making the transition

from routine to critical, but

720

in the future we kind of did.

721

You know, it wasn't something he called

out using this language, but if you

722

think about athletic team, coach,

doctor, platoon, commander, you name

723

it like a pilot on the radio, right?

724

We're flick-flacking between

routine and critical.

725

And sometimes the team, until they

really know our personality, they just

726

don't know when we're switching modes.

727

Preston: You know, one of the really

fascinating things, Coleman, is what

728

you just mentioned, is how many people

are like, well, how do they know

729

when I move from routine to critical?

730

They figure it out.

731

Well, okay, but we are now, and the

reason that we wrote this article, and

732

we reason that this is so important right

now is, let's go real time for a second.

733

We've got traditional intact teams in

medicine right now, frontline medicine.

734

Are being asked to go on what are

called swarms or X teams, where they

735

are deployed to work with a team they

may, may not have met before to rapidly

736

figure out something to resolve,

something to keep somebody alive.

737

We actually don't have time.

738

Anyone more for the team that

you may not be working again

739

with Again, to figure it out.

740

We have to do better than that.

741

Those old sort of

solutions where Oh, yeah.

742

You know, well, they'll

just figure it out.

743

No unacceptable.

744

We have to figure out a way that we need

to put in place early on to help our teams

745

know when we've made that transition.

746

Coleman: Yeah, for sure.

747

And as importantly, when I think about

just regular non frontline healthcare

748

workers dealing with what they're

dealing with today, which is just

749

like a combat deployment for them,

but typical day-to-day things, even

750

outside of a crisis environment, a

team can really, they don't have to.

751

Make it this big, huge thing

where you send up a red star

752

cluster, you know Right.

753

When you're going into critical,

that's not what we're saying, but if

754

teams know each other's style a little

bit better based on the things that

755

they typically deal with, you can

just get more out of each other, and

756

that's a great thing for any team.

757

Preston: Our mutual friend, Harry

Moffitt, who's a bit of a legend in

758

this world, one of the things I was

last year down in Australia with him.

759

And one of the things that he did with

his family and did with us, my wife and

760

I, he said, Hey, look, if there's ever

a situation where you hear me say, and

761

he said this literally as we were just

walking through the Melbourne, he said,

762

if you ever hear me say with me, just with

me, just get behind me and go where I go.

763

I thought it was just genius

because I'm in a foreign city.

764

I really don't know what's happening.

765

I don't know what he

sees that I don't see.

766

It was great because I immediately

knew what to do and I immediately

767

knew why he was switching, sort of

his communication style, and for me

768

that little expression was awesome.

769

Coleman: Preston, let's, for the

community, one of the things we're gonna

770

do is we come to the end of each segment.

771

We're going to always try to close

out with what to do on Monday.

772

It's important to us that the guests

that we have on in the future, the

773

topics that we discussed, that there

isn't just some, oh, good luck that

774

we drive all the way back down to

practical applications and some tactics.

775

So for the listeners, Preston, with

respect to routine and critical

776

communications or respect to anything

you want, what's a recommendation or

777

a tactic for what to do on Monday?

778

Preston: So here's some things

that we found really easy

779

to do and really successful.

780

Get your team together if you can, and

we'll go for right now with Intacct

781

teams and we'll talk about non-intact

teams, swarms and and X teams.

782

But let's start with intact teams.

783

Get your team together, have

everybody write down that if they were

784

gonna go into their boss on Monday

morning and have a meeting about,

785

you know, their future employment.

786

They wanted the meeting to be

congenial and to be relaxed and fun.

787

What are your five principles?

788

Have 'em write that down and then

share them together and you'll

789

find there's a lot of overlap

and everybody can nod and agree.

790

Okay, we all agree that courtesy,

respect, active listening, those

791

are, those are important things.

792

Then do the same thing.

793

Okay, we've got, we've got an emergency,

we've got a crisis, 300 seconds or.

794

Write down your five things and you're

gonna find clear, concise, direct.

795

You're gonna find overlap there too.

796

And if you do those things, you

can help everybody understand

797

what the difference is, right?

798

And then what you have to think

about is how are you gonna

799

communicate to each other.

800

When you're gonna have these environments,

when you're gonna make these changes.

801

So if you are in an environment that

you can control, like surgery, there are

802

literally things, simple things like have

music playing, and when the music turns

803

off, everybody switches to critical.

804

It's in the ambient environment.

805

That's the signal everybody put your

game face on, we're getting into it.

806

And then when the music comes

back on, take off your game

807

face, we can relax a little bit.

808

Right?

809

Or if you don't have technology, right?

810

Radio beeping, a visual

display or something like that.

811

Think about expressions.

812

The Marines have a great

expression of eyes.

813

I dunno if this is true in the Navy

or as well, but this idea, if somebody

814

yells at eyes, literally, that

means everybody should look at them.

815

Your eyes should look at them

and they'll tell you what to do.

816

But it's a great thing because it's quick

and to the point, eyes or ears, right?

817

And some communities that might

be too abrupt with me is lovely

818

or whatever, some sort of cue.

819

You can make it up for yourself and it can

be fun and it can be unique to your team.

820

There's been research done by, again,

Atul Gawande and others to show something

821

as simple as introducing yourself.

822

Wearing a name tag, shaking

someone's hand, or appropriate

823

physical touch can go a long way to

help cross some of these divides.

824

And so they're subtle, but they're

powerful because at the end of

825

the day, to go back from what we.

826

We talked about the

very beginning of this.

827

We're talking about

community and communitas.

828

We're talking about rules.

829

We're talking about tribe.

830

You could have rules, but you have to

remember we're still part of a tribe, and

831

the tribe has its own sort of way of doing

things and you have to account for that.

832

Coleman: Was there something on X

teams and swarms you wanted to add?

833

Preston: Yeah, so just really briefly, and

I, and I'll be more specific about that.

834

So in a situation where, in the

classic example in medicine is on a

835

resuscitation, somebody has coated

their heart, has stopped breathing, and

836

basically a group of people will have

their phones or their beepers go off

837

and they'll swarm to the patient and

they'll each have a role and they have

838

to execute that role quite quickly.

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They don't have a lot of time.

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There's not a lot of time to sit around

and being like, hi, my name's Preston.

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How are you?

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Gemini, that's not gonna work out right.

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But what you can do is you can have

certain things done ahead of time where

844

if you know the people that will get

pulled into a code, if you know the people

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who might join your team at some moment

to reach out to them prior to the event

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and literally just introduce yourself.

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Say, Hey, my name's Preston.

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Shake their hand physical touch.

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Say your name, say their name, and

you'd be surprised what can happen.

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And then let them know, Hey, in these

environments, here's the difference

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between routine and critical.

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In a resuscitation, we will

always be seeking critical.

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If I see any behavior that I don't

think is good, what I'll do is after

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the dust settles, I'll swing back

around to you in a routine environment

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over coffee or tea or water, and then

I'll gently sort of say, Hey, look.

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For you to move towards your potential.

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Here's some things to consider,

and that's the way you give

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feedback around those things.

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But you can't do it in the moment.

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You can't receive feedback in the moment.

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It's not useful.

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Coleman: Thanks for that.

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Preston, for the community, keep in

mind, doctors, first responders, nurses,

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frontline healthcare workers, especially

during this time or literally on a

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deployment, a domestic deployment.

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So to the extent that you can be.

867

Helpful to them.

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Try to do so.

869

Thanks for the time today.

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As usual, Preston,

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thanks for listening and

talk to you next time.

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Preston: Thank you again for

listening to our Teamcast.

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If you found value in this discussion,

the best way to support our work and

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ensure you don't miss future episodes is

to describe and leave us a quick rating

875

or review and help us reach more people

who need to hear these conversations.

876

For more on Mission Critical Team

Institute, including all of our episodes

877

and show notes, visit missioncti.com.

878

You can also connect with us on

LinkedIn, and if you're a mission

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critical team looking to learn more

about our programs, reach out directly

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to our director of Operations, Ms.

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Janese Jackson at janese@missioncti.com.

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That's j-a-n-e-s-e @missioncti.com.

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Until next time, thanks.