Three Problems with Top-Down Teams (and How to Fix Them)

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Three Problems with Top-Down Teams (and How to Fix Them)

A researcher shows how to encourage participation, influence, and even conflict.
Two doctors consult
While hierarchy is natural, the top-down approach in medical teams can hinder participation. | Reuters/Henry Romero

It’s a scene playing out in hundreds of hospital rooms across the world today: A doctor and a handful of nurses are discussing a plan of action with the patient and her family. Chances are, one person in the room is doing the majority of the talking, while everyone else listens and nods along.

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Left unchecked, this top-down team dynamic can lead to preventable negative outcomes for patients. At a recent Stanford Medicine X lecture, Stanford Graduate School of Business organizational behavior professor Lindred Greer described three problems with top-down team structures — whether in a hospital setting or an office — and shared tips on how to make better decisions as a group.

Problem #1: Not Enough Participation

Statistically speaking, decision-makers in a top-down team structure do 80% of the talking in a group setting, while everyone else contributes 20%, Greer says. More often than not, that 20% of the conversation is spent agreeing with the leader in the room.

“Doctors have a lot of knowledge,” Greer says. “But so do patients and nurses. If they’re not going to get their voices heard, you’re going to make ineffective decisions.”

While hierarchy is natural — stretching back to prehistory when hunters worked in teams and someone needed to take charge so the group could be successful — the top-down approach today hinders participation, particularly when someone has to gather the courage to challenge his or her boss.

“We have to combat what we naturally do — to fall into rank — to try to actually be equals with one another in the ways in which we interact, because everybody in the team has value, has voice, and [those voices] need to be heard to have good outcomes,” Greer says.

Solution: Foster a Different Environment

Greer encourages team leaders to create a climate “where it’s OK to make mistakes, it’s OK to say something that isn’t so smart, and it’s really OK to have a crazy idea.” Instead of dismissing ideas that challenge the working hypothesis, the leader should acknowledge the idea and attempt to incorporate it into the discussion.

Ahead of a group meeting, the leader should widely share the underlying data fueling the decision, so everyone has time to think about the problem and brainstorm possible solutions. Also, small meetings encourage more participation.

Problem #2: Influence From the Wrong Players

In top-down team structures, the leader holds more influence than others over the eventual decision. That’s dangerous when the team’s leader knows less about the subject than his or her team, Greer says.

She described a class exercise where Stanford undergraduates were asked to choose the smartest person in the room to lead them out of a theoretical desert. Researchers found roughly 50% of students were persuaded to choose a leader based on the person’s attractiveness, height, vocal intonation, facial features, gender and other arbitrary factors.

Students who chose their leader based on relevant knowledge “survived” the exercise; those who chose their leader based on arbitrary factors didn’t.

“When you’re in a meeting and everybody’s speaking up, it’s critical to make sure you’re listening to the right person,” Greer says. “That may not always be the tallest person or the person with the most seniority. It’s the person who knows most about this particular situation. That’s the challenge of teamwork: It’s going to change moment to moment, based on the discussion.”

Solution: Determine Who Deserves Influence

Ahead of the meeting, leaders should talk with their team to gauge relevant experience and knowledge related to the topic. For example, a junior nurse heading into a team meeting with a patient with a sports injury might volunteer to the doctor that he underwent a similar surgery in college.

“Taking the time to check in with a team before you get into a discussion about who has relevant knowledge is critical because otherwise you’re going to miss important insights and give influence to somebody who actually doesn’t deserve influence in this situation,” Greer says.

An easy way to flip the conversation’s dynamic is to allow the patient to lead the conversation’s direction, Greer says.

“Ideally it should be whoever knows most for that situation,” Greer says. “[When you] start to make a habit of realizing that formal leadership isn’t the same thing as running a discussion, you make it easier to have a culture where people can speak up and, if they know something relevant, take the lead.”

If a leader wants a culture where constructive disagreements can occur, she or he must be willing to take a background role.

Greer described meeting a CEO who subscribed to something he called the “hippo style” of management. In meetings, he found dominating the discussion and talking about his own ideas caused his team to stay quiet and not challenge the status quo. To fix that dynamic, he started opening up the discussion more in meetings, allowing himself to “sink below the water” like a hippo, watching and listening rather than constantly talking, Greer says.

‘Why’ is an incredibly powerful word in finding out why people really think what they do.
Lindred Greer

“In order to have the humility to let someone other than the formal leader lead, it means the person in charge of the team has to be a team player, and they have to be willing to let whoever knows most take the lead in that situation,” Greer says. “It doesn’t mean you’re not the leader, but it means in that situation, you’re letting other people have influence and rise up in their basis and knowledge.”

Problem #3: Not Enough Conflict

Ideally, patients, nurses, and doctors should be able to have an open conversation about treatment, with the goal of landing on the best health outcome possible. Good discussions involve constructive debate. A measurement of whether a debate is constructive is whether people are talking about solving the common problem ahead of them, or whether they’re arguing over power and influence. Research suggests 70% of debates that begin constructively devolve into emotional debates, Greer says.

“Having a culture of healthy disagreement is useful,” Greer says. “That means people having a voice, having leaders step down and being able to trust and respect everybody on the team enough that it’s OK to disagree.”

Researchers studied disagreements by teaching two groups of students a card game that contained largely similar rules, except for one key difference — one group was taught aces were the highest card in the game, while the other was taught aces were the lowest, Greer says.

The disagreement should have been easy to resolve, with students asking one another why they thought the ace card had different values. Instead, disagreements quickly got personal, with some students walking away from the game altogether. Other students resolved the conflict by blaming themselves, saying they must have learned the game’s rules incorrectly.

Solution: Understand Another Point of View

Greer offers an easy way to get to healthier conflict: Use the word “why.”

“If the doctor says, ‘We need to do this course of treatment,’ ask them why,” Greer says. “If the answer doesn’t make sense, keep asking why. Usually after four or five why’s you get the real answer. ‘Why’ is an incredibly powerful word to having constructive conflicts and finding out why people really think what they do.”

Using these communication and leadership tips in hospital settings can lead to better patient outcomes, something everyone can agree on.

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