Presentation
Everything Everywhere All at Once: Boundary Work and its Role in Shaping Outpatient Diagnostic Team Resilience
DescriptionMany healthcare teams are dynamic, lacking stable team membership and clear boundaries (Dihn et al., 2021; Kerrisey et al., 2023). In other words, healthcare providers often work with different people daily (e.g., emergency room teams) or with team members that are only there for a specific part of the task (e.g., inpatient medicine teams; Mayo, 2022). Across the board, healthcare often requires teamwork “across time and people,” which results in challenges, such as missing information between team members, poor patient experiences, and more (Mayo, 2022, p. 824; Tannenbaum et al., 2025).
Outpatient diagnostic teams face additional challenges while operating across time and people. They also operate across geographical locations. Oftentimes, the only forum for collaboration for outpatient diagnostic teams is the electronic healthcare record (EHR), but there are varied perceptions on its utility and role. Secondly, while many healthcare teams operate across time, outpatient diagnostic teams operate across time in every aspect of their work, not just one. Inpatient diagnostic teams also lack clarity on these factors (Mayo, 2022), but they are typically co-located, which provides some stability. This is less about whether their work is more complex and more about the unique, underexplored challenges outpatient diagnostic teams encounter (Choi et al., 2023). While all healthcare teams face some of these barriers, outpatient diagnostic teams face them every day, all at once.
Diagnostic errors in the outpatient setting are estimated to occur between 5% and 12% of visits, and most people will experience a diagnostic error in their lifetime (Singh et al., 2017; Watanabe et al., 2025). Drivers of diagnostic error rates are multifaceted, but primarily relate to what was pointed out 25 years ago in “To Err is Human” – issues with teamwork and communication (Choi et al., 2023; Kohn et al., 1999; Rosen et al., 2018). Tannenbaum et al., 2025). The need for dynamic teaming in a landscape of uncertainty makes it harder for outpatient teams to react and bounce back from challenges in a manner that sustains performance, a characteristic of teams known as team resilience (Alliger et al., 2015).
Dynamic teaming can make it harder to bounce back from challenges because it requires boundary work for effective performance (Tannenbaum et al., 2025). Defined as “the activities that a team engages in to establish and maintain boundaries and manage interactions across those boundaries,” boundary work can be competitive or collaborative (Faraj & Yan, 2009, p. 604; Langley et al., 2019). For example, team members can engage in competitive boundary work to assert territory (e.g., a provider saying “I’m the expert”) or collaborative boundary work to foster collaboration (e.g., a provider telling a patient “you’re part of the team;” Langley et al., 2019). More broadly, boundary work may involve clarifying responsibilities or drawing in members, such as specialists, who are often left out. Yet, the distinctive nature of outpatient diagnostic teams limits the applicability of the scant existing research in this area. Altogether, we know little about how dynamic teams engage in boundary work and its relationship to team resilience (Fernández Castillo et al., 2025; Tannenbaum et al., 2025).
We investigate the challenges that emerge during the outpatient diagnostic process, how teams respond to these challenges, and the role of boundary work in shaping responses to adversity. We utilized a multiple-case study design (Eisenhardt & Graebner, 2007) to combine electronic health record (EHR) data with qualitative interviews from patient–provider dyads working together to reach a diagnosis for new or worsening symptoms, to construct detailed diagnostic process chronologies. We then analyzed the adversities that outpatient diagnostic teams encounter and their responses to these events. Finally, we open-coded the original interview transcripts according to their boundary-work processes.
By studying these challenges and responses, we seek to develop a framework for understanding how clinicians’ and patients’ boundary work influences their ability to overcome adversity (i.e., team resilience; Alliger et al., 2015). This presentation has three main points: 1) the way patients and providers see their roles on the team affects how they handle challenges; 2) collaborative boundary work seems to be associated with less adversity in certain realms, such as team-based adverse events (e.g., interpersonal conflict; Raetze et al., 2025); and 3) the EHR can act like a bridge, helping everyone on the diagnostic team stay connected across time, places, and people. Below, we present a real patient’s case and discuss early insights from our data. All names are pseudonyms.
Maria, a patient with limited English proficiency (LEP), came for a vaccination but began feeling unwell in the outpatient clinic lobby. A provider she had never met evaluated her. From Maria’s perspective, this provider seemed disengaged and unconcerned with her symptoms, which resulted in Maria feeling rushed, unheard, and frightened. After this experience, Maria went home and switched providers (to an entirely different clinic). With her new doctor, who explained her condition and results clearly, her symptoms eventually resolved.
During her interview, Maria consistently refers to “my new doctor” versus “my old doctor,” and identifies only her new provider as part of her diagnostic team (Langley et al., 2019). This reflects competitive boundary work. Meanwhile, Maria’s original provider discussed that she “will be communicating to her primary care provider, which is [the] physician who is listed in her chart, [that she] is the prime, ultimate, responsible person for that patient […],” also reflecting competitive boundary work, emphasizing her role as limited to that visit. While there is no issue with a provider only seeing a patient once or having a short interaction, the problem here lies in Maria’s providers’ lack of task interdependence. Each professional is treating their responsibilities as discrete and non-overlapping rather than as interconnected pieces of a shared diagnostic process. Without recognizing how their roles rely on one another to ensure continuity of care, the team fragments into silos, leaving Maria to navigate the diagnostic process alone.
Maria’s case illustrates common diagnostic breakdowns, such as poor communication between practitioner and patient (Singh et al., 2013). In the case of more serious symptoms or sicknesses, the amount of time it can take for a patient to find a new provider, schedule, and attend another visit can result in weeks of delays on the order of weeks or months, a matter that can be the difference between life and death. Viewed retrospectively, these breakdowns become clear. Maria’s original provider framed her role as limited to one encounter, effectively ending her responsibility once Maria left the clinic. This narrow view helps explain why the visit felt rushed: Maria was not seen as the original provider’s ongoing responsibility, so there is limited logic in spending extended time and effort with her. Targeted interventions for outpatient diagnostic teams could address issues like practitioner–patient communication and, symptom dismissal, all previously cited problems contributing to error (Singh et al., 2013). But alternatively, interventions could focus on the root of these issues: the patient and the provider’s attitudes about their role on the team. Existing literature establishes attitudes as precursors of habits (Verplanken & Orbell, 2022). Here, we explore the possibility that by focusing on reshaping how people conceptualize their team role and identity, certain challenges can be potentially mitigated or avoided altogether.
Our presentation will seek to discuss cases like the above, from patients who were ultimately diagnosed with cancer to patients whose symptoms resolved and were never officially diagnosed. We fill a gap in the literature by examining a context that represents today’s dynamic environment (Dibble & Gibson, 2018), and how boundary work supports/undermines resilience (de Vries et al., 2023).
References available upon request.
Outpatient diagnostic teams face additional challenges while operating across time and people. They also operate across geographical locations. Oftentimes, the only forum for collaboration for outpatient diagnostic teams is the electronic healthcare record (EHR), but there are varied perceptions on its utility and role. Secondly, while many healthcare teams operate across time, outpatient diagnostic teams operate across time in every aspect of their work, not just one. Inpatient diagnostic teams also lack clarity on these factors (Mayo, 2022), but they are typically co-located, which provides some stability. This is less about whether their work is more complex and more about the unique, underexplored challenges outpatient diagnostic teams encounter (Choi et al., 2023). While all healthcare teams face some of these barriers, outpatient diagnostic teams face them every day, all at once.
Diagnostic errors in the outpatient setting are estimated to occur between 5% and 12% of visits, and most people will experience a diagnostic error in their lifetime (Singh et al., 2017; Watanabe et al., 2025). Drivers of diagnostic error rates are multifaceted, but primarily relate to what was pointed out 25 years ago in “To Err is Human” – issues with teamwork and communication (Choi et al., 2023; Kohn et al., 1999; Rosen et al., 2018). Tannenbaum et al., 2025). The need for dynamic teaming in a landscape of uncertainty makes it harder for outpatient teams to react and bounce back from challenges in a manner that sustains performance, a characteristic of teams known as team resilience (Alliger et al., 2015).
Dynamic teaming can make it harder to bounce back from challenges because it requires boundary work for effective performance (Tannenbaum et al., 2025). Defined as “the activities that a team engages in to establish and maintain boundaries and manage interactions across those boundaries,” boundary work can be competitive or collaborative (Faraj & Yan, 2009, p. 604; Langley et al., 2019). For example, team members can engage in competitive boundary work to assert territory (e.g., a provider saying “I’m the expert”) or collaborative boundary work to foster collaboration (e.g., a provider telling a patient “you’re part of the team;” Langley et al., 2019). More broadly, boundary work may involve clarifying responsibilities or drawing in members, such as specialists, who are often left out. Yet, the distinctive nature of outpatient diagnostic teams limits the applicability of the scant existing research in this area. Altogether, we know little about how dynamic teams engage in boundary work and its relationship to team resilience (Fernández Castillo et al., 2025; Tannenbaum et al., 2025).
We investigate the challenges that emerge during the outpatient diagnostic process, how teams respond to these challenges, and the role of boundary work in shaping responses to adversity. We utilized a multiple-case study design (Eisenhardt & Graebner, 2007) to combine electronic health record (EHR) data with qualitative interviews from patient–provider dyads working together to reach a diagnosis for new or worsening symptoms, to construct detailed diagnostic process chronologies. We then analyzed the adversities that outpatient diagnostic teams encounter and their responses to these events. Finally, we open-coded the original interview transcripts according to their boundary-work processes.
By studying these challenges and responses, we seek to develop a framework for understanding how clinicians’ and patients’ boundary work influences their ability to overcome adversity (i.e., team resilience; Alliger et al., 2015). This presentation has three main points: 1) the way patients and providers see their roles on the team affects how they handle challenges; 2) collaborative boundary work seems to be associated with less adversity in certain realms, such as team-based adverse events (e.g., interpersonal conflict; Raetze et al., 2025); and 3) the EHR can act like a bridge, helping everyone on the diagnostic team stay connected across time, places, and people. Below, we present a real patient’s case and discuss early insights from our data. All names are pseudonyms.
Maria, a patient with limited English proficiency (LEP), came for a vaccination but began feeling unwell in the outpatient clinic lobby. A provider she had never met evaluated her. From Maria’s perspective, this provider seemed disengaged and unconcerned with her symptoms, which resulted in Maria feeling rushed, unheard, and frightened. After this experience, Maria went home and switched providers (to an entirely different clinic). With her new doctor, who explained her condition and results clearly, her symptoms eventually resolved.
During her interview, Maria consistently refers to “my new doctor” versus “my old doctor,” and identifies only her new provider as part of her diagnostic team (Langley et al., 2019). This reflects competitive boundary work. Meanwhile, Maria’s original provider discussed that she “will be communicating to her primary care provider, which is [the] physician who is listed in her chart, [that she] is the prime, ultimate, responsible person for that patient […],” also reflecting competitive boundary work, emphasizing her role as limited to that visit. While there is no issue with a provider only seeing a patient once or having a short interaction, the problem here lies in Maria’s providers’ lack of task interdependence. Each professional is treating their responsibilities as discrete and non-overlapping rather than as interconnected pieces of a shared diagnostic process. Without recognizing how their roles rely on one another to ensure continuity of care, the team fragments into silos, leaving Maria to navigate the diagnostic process alone.
Maria’s case illustrates common diagnostic breakdowns, such as poor communication between practitioner and patient (Singh et al., 2013). In the case of more serious symptoms or sicknesses, the amount of time it can take for a patient to find a new provider, schedule, and attend another visit can result in weeks of delays on the order of weeks or months, a matter that can be the difference between life and death. Viewed retrospectively, these breakdowns become clear. Maria’s original provider framed her role as limited to one encounter, effectively ending her responsibility once Maria left the clinic. This narrow view helps explain why the visit felt rushed: Maria was not seen as the original provider’s ongoing responsibility, so there is limited logic in spending extended time and effort with her. Targeted interventions for outpatient diagnostic teams could address issues like practitioner–patient communication and, symptom dismissal, all previously cited problems contributing to error (Singh et al., 2013). But alternatively, interventions could focus on the root of these issues: the patient and the provider’s attitudes about their role on the team. Existing literature establishes attitudes as precursors of habits (Verplanken & Orbell, 2022). Here, we explore the possibility that by focusing on reshaping how people conceptualize their team role and identity, certain challenges can be potentially mitigated or avoided altogether.
Our presentation will seek to discuss cases like the above, from patients who were ultimately diagnosed with cancer to patients whose symptoms resolved and were never officially diagnosed. We fill a gap in the literature by examining a context that represents today’s dynamic environment (Dibble & Gibson, 2018), and how boundary work supports/undermines resilience (de Vries et al., 2023).
References available upon request.
Event Type
Oral Presentations
TimeTuesday, March 242:00pm - 2:30pm EDT
LocationMurray Hill East
Patient Safety Research and Initiatives