Sklar, David P. MD
It was one of those days. There were too many patients and nothing seemed to be going smoothly. The nurses continued to request help with problems that we thought had been solved much earlier, and patients were complaining about the long waits for care. I had not worked with the resident on my team before, and we were trying to get to know each other’s style and establish rapport and trust in between the incessant interruptions. She seemed to be competent, and I was becoming comfortable with her approach to the patients and the consultants.
In the middle of all this, we were paged to attend to a woman arriving by ambulance who was having shoulder spasms. I sighed. It did not sound like a straightforward problem, and we had several unresolved issues that we needed to address for other patients. But off we went to meet with the paramedics. As we arrived, two of them were unloading a white-haired woman onto a bed in the resuscitation bay. They began their report:
This 61-year-old female called the ambulance after she noted that her right shoulder would not stop twitching. We have observed the entire shoulder and right arm to twitch in spasms, but the patient has maintained consciousness and has no complaint of headache or other neurological history. Her vital signs have been normal. The shoulder stopped twitching during transport and she had residual weakness in the right arm, and then the shoulder began twitching again just prior to arrival.
The resident and I watched while the woman grimaced as her shoulder continued to twitch rhythmically. It was horrifying in a different way from someone covered with blood. This was a case of a body part out of control, as if taken over by some alien force, while the rest of the body struggled to comprehend and exert some countervailing action. We waited to see whether the twitching would stop, and I looked at the resident to see what she wanted to do. She had not seen something like this before. I remembered a few similar cases over my years of practice; it is something one doesn’t forget.
“Let’s call the stroke team,” she said. “I think this could be a stroke.”
We called the stroke team, although I did not think that a stroke would prove to be the cause of the problem. We questioned the woman about her medical history and the events leading up to this event. A pharmacist arrived. She was part of our team and suggested some medication to stop the spasms; ultimately, we decided to try an antiseizure medication. We brought the patient to the CT scanner accompanied by our team of nurses and technicians, and the stroke team arrived just as the results of the CT scan were scrolling past on the monitor. “Oh, too bad,” said the neurology resident. “You’ll need to call Medicine and the oncology team for that,” she added as she recognized the two metastatic lesions in the brain that were causing the seizure activities in the woman’s arm and shoulder. We soon received a confirmatory call from the radiologist who had seen the film.
The resident and I looked at each other, still feeling the anguish of the woman’s sudden descent from health to a likely fatal condition, and neither of us could speak. Our team of nurses, techs, pharmacist, and paramedics awaited orders. By now the woman’s arm had stopped twitching. She explained that she had been healthy her entire life. She worked at the post office and never saw doctors. She lived alone and had no children, although she had a sister in Santa Fe. When the spasms hit her, she thought it might be the end. She had felt her life slipping away, but then the spasms had stopped. She was so grateful for the paramedics and the emergency department staff.
I was thinking about how we were going to tell her what the tests had shown. I wondered whether she might want to call her sister. And so we began to explain the findings and our own uncertainty about what they meant. We would need to consult other specialists and do more tests. Our team would enlarge to involve specialists from internal medicine, oncology, and neurosurgery. The patient would be admitted to another team of inpatient doctors. The woman nodded as the words began to sink in. Meanwhile, the rest of our team—the nurses and physician’s assistant caring for our other patients in different parts of the department—began to approach us, like encroaching waves of a rising tide on a beach, hoping we might be able to shift our attention to their patients. The resident and I shared one final look before we nodded that we were done here.
As I hurried off with our physician assistant, who had a patient with hyper tension and a headache, I began to calculate the number of all the health care providers who had been working with me to help the patient with shoulder spasms: two nurses, a radiology technician, a neurology resident, a radiology resident, two paramedics, an emergency medicine resident, and a pharmacist. And there were the nurses and the physician’s assistant caring for our other patients as the resident and I focused on this one. In addition, we would soon be involving a social worker to deal with financial and social issues, and maybe the patient would want the hospital chaplain.
Teams are an integral part of my practice. Usually they have worked well, but I can remember several times when they haven’t. Once I disagreed with the pharmacist about administration of an intravenous medication, and she refused to prepare what I wanted. The nurse did not know what to do, and so care was delayed as the patient’s condition worsened. Our failure to agree on a mechanism to resolve such a conflict was both upsetting and dangerous, and we all determined not to let it happen again. There was also a time when a physician colleague had arrived during a crisis with one of his patients and gave orders that contradicted what we had been doing before he appeared. The nurses did not know whose direction to follow, and our teamwork temporarily broke down until we could establish some order.
These and other experiences made me realize that teams are fragile and can become disrupted through problems with leadership, inadequate training, or unexpected circumstances, but that teams are also critical to our success throughout the health care system. I needed to know more about how to optimize their function. What are the strengths and weaknesses of interprofessional teams, what are the barriers to their success, and what can be done to help make them function well?
Mitchell et al1 describe the many forms of teams in health care. Teams have moved beyond emergency departments, operating rooms, and critical care units to include home care, chronic care management, ambulatory care, and end-of-life care. The authors explain the rapid growth of teams as a response to the increasing complexity of health care, especially in the areas of knowledge, skills, and geographic location. Although each health care team is unique, Mitchell et al identify five principles that all health care teams should follow: they should have shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes. The authors emphasize the importance for institutional leaders to embrace these principles, and also emphasize the central role of including patients and their families as parts of the team.
However, there are also impediments to achieving the goals of team-based care, which have been identified as absence of role models, reimbursement limitations for team-based care, resistance to change related to power issues between professions, and logistical barriers for team-based education.2 Also, Haddara and Lingard,3 through a critical discourse analysis of interprofessional collaboration literature from 1965 to 2011, identify power and dominance struggles between the professions as a major discourse that is often in conflict with another discourse, the demonstration of higher-quality care through interprofessional collaboration.
My own perception is that we have not yet achieved the promise of teams to bring about a more efficient and safer health care system even as new team members proliferate. We have limited evidence of the efficacy of interprofessional team education on improvements in care outcomes.4,5 Our current fee-for-service payment system encourages competition between team members. Our hierarchical care delivery culture persists and makes collaborative leadership difficult even when the delivery culture is recognized as a problem.6 Both issues will need to be addressed if interprofessional collaborative practice is to succeed. Payment systems that provide incentives for team-based care, such as bundled payments or capitated payments, could help drive the development of delivery system changes like patient-centered medical homes and chronic care models that we will need to support the students we are beginning to train for these new approaches. Even in fee for service, we can add codes to reward interprofessional management of chronic diseases. In capitated and global payment systems we can share the rewards of reduced hospitalization and other expensive care.
We will also need to overcome cultural barriers to interprofessional collaboration through raising awareness and practicing how to work together effectively. I also believe that more research that proves the value of team-based care will help to convince physicians that this form of care is often superior to the care provided by individual physicians. Recent research provides conflicting results that will require resolution.7
Issues of teams are implicit in the journal’s 2013 Question of the Year, “What is a doctor? What is a nurse?”8 which I posed to stimulate the creative thinking of our community on those two questions. Our respondents were consistent in their encouragement for health care providers to break down the barriers between health care professionals and to recognize the important contributions that these professionals can all make as members of health care teams. Romano and Pangaro9 in this issue of Academic Medicine summarize the respondents’ views and go on to encourage renewed efforts to discard outmoded ideas of identity and redefine ourselves to improve collaboration and teamwork. Also in this issue, ten Cate10 identifies questions for us to consider in attempting to define a future physician. He asks us to consider the future professional identity of physicians and challenges assumptions about length of training, type of training, and the roles of other members of the health care team. These and other issues that he points out will be critical as we redefine curriculum, admission standards, and the evaluation of competence, and as we redesign delivery systems, consider workforce requirements, and align payments to provide appropriate incentives to achieve our health care goals.
In making many of the changes listed above, we will need to find ways to ensure that teams, and thus the members of teams, can function to their full potential. Just as my patient had a completely normal arm and shoulder—the muscles and nerves and bones were all perfectly healthy—and yet could not coordinate the arm with the rest of the body, we now have health care team members who are perfectly competent and highly motivated but are unable to function to their full capacity. Their reduced function through lack of coordination and empowerment leaves our health care system less capable and efficient than it could be. But by using the wisdom of our community, we can fix the problems with health care teams through education, leadership, and payment incentives that will support delivery system changes. For if we enlarge and broaden our identities and encourage activities that support and enhance the work of all our teams, we will improve the availability, cost, and quality of care for our patients.
David P. Sklar, MD
1. Mitchell P, Wynia M, Golden B, et al. Discussion Paper: Core Principles and Values of Effective Team-Based Health Care. 2012 Washington, DC Institute of Medicine www.iom.edu/tbc
. Accessed March 7, 2014
2. Conference Proceedings February 16–17, 2011. . Team-Based Competencies: Bulding a Shared Foundation for Education and Clinical Practice. 2011 Washington, DC Josiah Macy Foundation, ABIM Foundation, Robert Wood Johnson Foundation and Interprofesional Collaborative www.aacn.nche.edu/education-resources/IPECProceedings.pdf
. Accessed March 7, 2014
3. Haddara W, Lingard L. Are we all on the same page? A discourse analysis of interprofessional collaboration. Acad Med. 2013;88:1509–1515
4. Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: Effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev. March 28, 2013;3:CD002213
5. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the MedTeams project. Health Serv Res. 2002;37:1553–1581
6. Lingard L, Vanstone M, Durrant M, et al. Conflicting messages: Examining the dynamics of leadership on interprofessional teams. Acad Med. 2012;87:1762–1767
7. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311:815–825
8. Sklar D. Question of the year: What is a doctor? What is a nurse? Acad Med. 2013;88:3
9. Romano CA, Pangaro LN. What is a doctor and what is a nurse? A perspective for future practice and education. Acad Med. 2014;89:970–972
10. ten Cate O. What is a 21st-century doctor? Rethinking the significance of the medical degree. Acad Med. 2014;89:966–969