Interprofessional teamwork in health care can be defined as “a type of work which involves different health and/or social professions who share a team identity and work closely together in an integrated and interdependent manner to solve problems and deliver services.”1 Such an approach to health care provision has been growing in popularity in recent years; many influential health care bodies are now advocating for collaborative care as an imperative for providing optimal, patient-centered care.2–4 Moreover, Health Canada links interprofessional collaboration in health care with “greater provider satisfaction.”5
Interprofessional collaboration has long been a focus of study and discussion in medical education, with an emphasis on interpersonal, individual-level phenomena, such as working in teams, as well as on systematic analysis of care processes involving multiple medical specialties.6–8 There is now a growing research basis for interprofessional collaborative care.9,10 Although some studies have demonstrated benefits of team-based care,10 uncertain diagnosis has been identified as a “high-risk trigger for dangerous handoffs” between health care team members, and there is little agreement as to how this process can be standardized.11 For the purposes of this study, health care provision is interprofessional and collaborative when a team composed of health care professionals from a range of relevant specializations are “working collaboratively, [and when] they seek common goals and can analyze and address any problems that arise.”12
Teamwork between health care providers of the same profession, or intraprofessional care, can also pose challenges related to communication and uncertainty of diagnosis.13 Comparably less research has examined the nature and outcomes of intraprofessional collaboration. This is a significant omission in the literature, given the rising rates of hospital admissions for complex patients with medical and social problems that require the expertise of multiple physician specialties.14 To explore this underresearched aspect of health care provision, our study examined intraprofessional collaboration between physicians in an academic hospital in Canada in order to explore optimally successful intraprofessional collaboration between physicians (faculty and trainees) in the emergency department (ED) and those from the internal medicine service (GIM).
We were particularly interested in how intraprofessional interactions affect medical education. In the harried and stressful environment of acute care hospitals, medical educators have to balance the educational needs of their trainees with the clinical needs of their patients and the administrative goals of their institutions. As a result, trainees in the clinical workplace are exposed not only to the formal curriculum mandated by their institutions and the informal curriculum taught purposefully by their clinical preceptors but also to a “hidden curriculum.” The hidden curriculum, first described in the medical education literature by Hafferty,15 refers to “cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavours.”16 For Hafferty, there is often significant incongruence between the stated goals and methods of the formally endorsed medical curriculum and what is actually modeled and deployed in policy, evaluation, and institutional practice. The applicability of the hidden curriculum for our study arose out of the data itself and was not predetermined. During observations and interviews, we encountered frequent reference to concepts and strategies that were not included in medical students’ formal curriculum but that were modeled and taught to them by their mentors in the clinical context.
The original impetus for the study was an observation among physicians on our team of increasing tension between residents in the ED and in the GIM at the point of consults. On the one hand, ED residents complained about long waits for consultations and ward admission. On the other hand, the GIM residents were dismayed by the amount of inappropriate consultations they received from the ED.
Further, in 2008, the Ontario government introduced a strategy to reduce ED wait times, with speed of processing as a key focus of measurement. Hospitals are monitored and ranked, and data are publicly provided in “stocktake” reports that are intended to inform a “performance management approach.”17 Previous Canadian research has examined the impact of wait times management strategies on nurses in the ED.18 Our study builds on this literature by considering the perspective of physicians and the impact of wait times management on hospital wards that provide consultations to, and receive admissions from, the ED.
We obtained institutional research ethics approval for an observational study of intraprofessional interactions in the health care environment focusing on the moment of specialty consultation. Data collection took place in 2010 and 2011. Our primary method was ethnographic participant observation.19 Ethnographic methods have increasingly been used by multidisciplinary research teams to understand the many complex interactions and processes involved in clinical medical education.20–23 Ethnography allows researchers to directly observe “what actually happens” in a particular social environment.23 Our observations were supplemented with ad hoc interviews with residents, nurses, and faculty from both GIM and ED in the field. Data collection and analysis were undertaken in an iterative fashion until saturation was reached.24
Data were collected by a medical anthropology student (K.R.) under the direct supervision of an experienced sociologist with extensive training in ethnographic data collection in medical settings (F.W.). The observer’s entry to the field involved shadowing both ED and GIM residents. To control for Hawthorne effects,25–27 K.R. dressed in a lab coat like a medical student and carried a notebook. However, she was always appropriately identified by a name tag, which specified her status as “research associate” (RA), and all members of the ED and GIM teams were informed that the study was taking place.
Over 60 hours of observations took place in the ED and on the GIM ward. More observations took place at night and on the weekends because of a higher volume of nighttime and weekend consults; these were often more stressful because of additional pressures, such as an absence of technical personnel to carry out necessary medical tests at these hours. In addition to quietly observing, the RA also engaged in unstructured research-related conversation with physicians in the ED and GIM. These conversations focused on challenges to providing optimal ED patient care in a major academic trauma hospital, the challenges of meeting the new wait time targets, the nature of interactions with GIM doctors (for ED doctors) or ED doctors (for GIM doctors), and the challenges of balancing patient care with teaching of medical students. The RA also asked for information and clarification regarding various relevant patient cases that came up during these observations. During observations, the RA took scratch notes that were later expanded into ethnographic field notes (see Box 1).28 In keeping with research ethics protocols, identifying information was always omitted, the RA never accompanied a physician to the patient bedside, and she did not interact with patients or their friends and families.
Box 1 Sample Field Notes From Observations of Emergency Department (ED) and Internal Medicine Physicians, Ontario, Canada, 2010–2011 Cited Here...
Clinical Care Leader (CCL) Rolea
The CCL comes back in and says flatly, “They’re not admitted” [presumably discussing the same patient as before]. Dr. M says flatly, “She’s admitted.” CCL: “No, she’s not.” Dr. M sounds angry: “Yes, she is.” CCL: “There’s no record of it.”… Dr. M says, “I’m filling out the paperwork right now.” The CCL leaves, and Dr. A vents a bit about the rude behavior of the CCL. Dr. A specifies that it’s not just that she’s a CCL. It’s this … CCL. [Overnight observation, senior resident ED, Shadow #1]
The female patient is 92, came from a retirement home with no medical history whatsoever. She seems unconscious and is nonverbal. She had a stroke today.… The family says that the patient had a possible stroke in September, and that the patient did not see a doctor. Senior resident asks, “When did this [the stroke] happen?” [Another] resident replies, “It’s at least two hours old.” She leaves. [Senior resident] turns to me and says, “It’s failure to cope.” [Observation #1]
I ask S if he can tell me a bit about the consult to Medicine that he had done in the morning, before I arrived for observation. He says: “Sure. It’s the woman with the cough. It was a failure-to-cope situation. She’s been transferred to medicine, but we’re waiting for a test result. Her salt is really low, she’s got a lot of water on her. So she has to stay.” [Observation #3]
The resident arrives. She’s friendly, asks a few questions about what I am doing and whether I will always be shadowing her. I give a short explanation and say that I’ve been shadowing different people each time.… She is looking over her patient list while she’s talking to me, and says something along the lines of “Dr. X always says, ‘Don’t do any tests.’” I want to ask her what she means, but she points to a woman in a bed across the zone and says: “There’s a failure to cope. She went home yesterday, and is readmitted. Follow me. We’ll start by collecting stickers.” I follow her out the door to another zone. [Observation #4]
At this point S leans in and says, “See, like that, that’s what I was telling you about,” and points through the glass at Dr. L and the woman with the scrub hat. She’s standing at the counter of the nursing station, discussing something with Dr. L and writing in a clip board at the same time.… “She [the patient] was discharged from medicine, and so she’s [the physician] trying to argue that the patient should go back to medicine because they were discharged from medicine.” I ask, “You mean the patient was sent home from medicine, and is back in the hospital?” S says, “Yeah.” I ask why [department] wouldn’t want the patient. He tells me that no one ever wants an extra patient, because it means another case to discuss in rounds. I ask why the patient is back in the hospital, and he says that “she’s COPD [chronic obstructive pulmonary disease], can’t cope, needs steroids.” [Observation #6]
aThe CCL is a nurse who is responsible for making sure that the hospital meets wait time targets by ensuring that patients are discharged or admitted quickly. The CCL circulates the ED, doing whatever he or she can do to advance this goal.
When telephone consults took place, the RA would observe and then ask the physician requesting the consult questions about the nature of the consult directly after the call. When the ED physicians were busy at the patient bedside, the RA would sometimes do observational rounds of the ED zones. Outside of business hours (8 AM–5 PM), members of the GIM team were often present in the ED, and it was often possible for the RA to be physically present for consults between the ED and GIM physicians. In addition to collecting observational data, the RA also shadowed both ED and GIM residents. Through shadowing, the RA was better able to observe the obligations and pressures experienced by individual residents over the duration of a shift. Moreover, because GIM residents’ work involves regular mobility back and forth between the GIM ward and the ED, shadowing was the only way in which the RA could observe the full scope of a GIM resident’s work throughout the duration of a shift. Five residents each on the GIM and ED teams were shadowed during overnight shifts.
To expand on topics raised during observations and shadowing, the same RA conducted one-on-one interviews with staff and residents from both the GIM and ED teams. The chief of staff sent an e-mail to all staff and residents in both the ED and GIM, notifying them of the possibility of being interviewed for the study. All 12 willing respondents who replied to the chief of staff and shared their contact information with the RA were subsequently interviewed. The participants included equal numbers of staff and residents. Each interview lasted approximately 30 to 45 minutes.
The RA debriefed with the lead investigator (F.W.) following observations and interviews. Interviews were digitally recorded, transcribed, and coded thematically using MAXQDA Version 8 (VERBI GmbH, Berlin, Germany) qualitative data analysis software. All transcripts were read independently by two researchers (F.W. and K.R.), and the codes were entered into the software by the RA. Codes were organized into categories, and emergent themes were presented to the larger research team for further discussion and analysis across several meetings.
Our analysis drew on concepts from institutional ethnography (IE). IE recognizes that people’s everyday lives are sites of interface between individuals and a vast network of institutional relations, discourses, and work processes; it takes as its object of interest this interface between embodied individuals and institutional relations. IE emphasizes “a person’s experience of their own work”29 and examines how their work is coordinated with that of others. IE researchers explore the experiences of real people in actual settings by seeking to understand their standpoint. In our study, we took up the standpoint of internal medicine physicians as an entry point for our investigation of the social relations organizing consults between ED and GIM. In conducting observations and analysis, we also drew on Hafferty’s15 concept of the hidden curriculum, designing our study with an eye to “what students learn, instead of what they are taught.”
Two key aspects of the hidden curriculum, described in detail below, stood out over the course of our research. First, participants described an impression that efficiency is understood as being more important than education and has in fact become the new definition of “good” patient care. Second, the persistent use of the informal term “failure to cope” to describe high-needs patients suggests that they were viewed as a unit of work—and in many instances experienced as a barrier to optimal efficiency—rather than as individuals requiring care. The participants described engaging in practices that avoided or redirected patients; indeed, having to perform patient care was often negatively associated as having less power than others on the team.
Efficiency trumps education
Repeatedly, participants’ accounts of their approach to teaching referred explicitly to efficiency. Although the formal curriculum may emphasize accurate diagnosis and high-quality, patient-centered care as the overarching objective for ED and GIM physicians, during structured interviews, informal conversations, and observations, we found a clear emphasis on efficiency instead. For example, when asked how he teaches residents and students consultation skills, a staff ED physician responded:
I try and teach efficiency … really my focus down there [ED] is on efficiency and workflow, so that’s what I sort of try and teach them. [Staff ED physician]
Several physicians noted that the emphasis on efficiency sometimes comes at the expense of providing good training to medical students and junior residents:
The department is being funded based on meeting performance targets, so trying to get people either referred quickly or out of the department quickly. So that’s one issue, and that leads probably to earlier referrals than we would have in the past. It probably leads to less learning opportunities for our trainees because there’s increasing pressure to get the patient referred quickly or to send them home quickly so, you know, the procedure that you would have had your trainee do is now going to be referred to the consultant. [Senior ED physician]
Physicians from both the ED and GIM told us that they were often not able to diagnose patients before referring them to a specialty because of the pressure on ED physicians to admit or discharge patients as quickly as possible. Rather, the ED physicians would often eyeball patients, ascertain they were ill, and refer them to an admitting specialty—usually GIM, especially if the patient was frail and elderly. This did not actually cut down on the amount of time that the patient waited for care, but it did transfer the work out of the ED.
Perhaps the strongest evidence that efficiency has become a paramount priority is the creation of a new role in the hospital that was developed to address the wait times issue. The clinical care leader (CCL) is a nurse who is responsible for making sure that the hospital meets wait time targets by ensuring that patients are discharged or admitted quickly. The CCL circulates the ED, doing whatever he or she can do to advance this goal.
Physicians’ impressions of the CCL role were uniformly negative:
It’s [the CCL] a useless position. I mean, maybe there’s something they’re doing that I don’t see, but in my interactions with them, if anything they just take up more time and slow us down … we’re always balancing competing interests, and to have a person whose sole job, it seems to be, is to tell you to work faster, is just … you know, it’s poor judgment, it’s insulting, and it causes a lot of friction between the emergency room and medicine. [GIM resident; emphasis ours]
The CCL was evidently a source of stress on staff and residents alike. There was almost unanimously expressed negative feedback on the CCL role, especially from residents. It was clear that students and residents understand the CCL not as a role that exists to provide better patient care but, rather, as one that reinforces the hidden curriculum of efficiency. In the following example, a GIM resident expresses the impression that the CCL is there to “offload to Medicine”:
I think the big thing is having the [CCL], having a way to offload [to] Medicine with the gray area consults, I think that’s the biggest change. I think that’ll improve the Emergency efficiency more than any other intervention. [GIM resident]
However, in making the ED more efficient by transferring these “gray area consults” to GIM, GIM staff and residents come to feel undervalued and taken advantage of:
Sometimes I think it’s personal, but at other times it’s just, I think, the stress that’s on everyone to meet the demands of seeing a lot of patients. For instance, on Medicine we’re more than happy to see patients who we consider … you know, I guess the word would be “appropriate” for us, but we don’t … we often feel like we’re getting taken advantage of. [GIM resident]
Failure to cope
During initial observations, we noted the pervasive use of the term “failure to cope” as a description of certain patients. During an evening observation, one GIM resident explained to the RA that a newly admitted patient was a “failure to cope,” and continued by reflecting that “we’re getting a lot of these failure to copes today.” We subsequently paid particular attention to how this term was used, asking for further clarification when necessary.
Failure to cope was frequently used in a diagnostic sense. Although it is not a recognized medical condition or diagnostic category, a number of physicians implied that it was a legitimate diagnosis:
GIM RESIDENT: So, failure to cope is a very interesting diagnosis. There’s not a lot of literature on the topic, but a failure to cope … can encompass a lot of different things but generally it’s felt to be someone who doesn’t have a clear overriding medical problem, or at least not an acute medical problem, but is not safe or well supported enough to continue living in their current situation.
RA: Now, when that person comes into the emergency room, will the ED docs actually refer that patient to you guys as a failure to cope?
GIM RESIDENT: Yeah, they will.
There seemed to be a consistently articulated understanding of what a typical failure-to-cope patient “looks” like. Physicians expressed this during formal and informal interviews as elderly, frail, likely confused, and otherwise unable to look after daily needs without help. Yet failure to cope was clearly not descriptive of the patient’s medical condition. One participant said the term is used
if there’s no obvious diagnosis but you just don’t think the patient can go home or maybe it’s not a great social situation or they’re elderly and then maybe the rest of the team is pretty busy. [ED resident]
Other physicians also noted that the failure-to-cope diagnosis is often related to needs that they understand to be “social” in nature:
They’re not really being admitted for a medical reason, they’re being admitted for a social reason. [GIM resident]
In addition to being understood as a social diagnosis, failure to cope was also described as a sort of hidden diagnosis in the context of medical coding and billing:
And the thing is, in order to meet the requirements for the Ministry of Health billing, that’s not a diagnosis that is recognized—like, you can’t put a code on that—so you have to find something, which may be sort of misrepresenting the case of what the patient actually has.… But someone who is purely just a social admission, you have to be pretty creative to come up with a billing code, otherwise you’re not going to get paid for the work you’re doing. [GIM resident]
“Social” admissions seemed to be understood as sharply distinguished from “medical” patients, whose health problems were more easily identified, isolated, and treated through strictly biomedical means. Both staff and residents also suggested that failure-to-cope patients somehow have a less legitimate claim to hospital bed space, indicating that these patients “block” beds that could better be used by others:
When you’re running at 110% capacity it’s disheartening to see a failure to cope because you know that they may end up tying up a Medicine bed for very long period of time that someone who is acutely ill is not going to have access to. [GIM clinical associate]
They’re time consuming and they’re not as great educationally and they tend to block beds. I understand they’re still people and still need care but those are challenges for us. [Senior GIM physician]
These accounts focus on the patient as failure, yet there is also a less-visible accounting logic embedded within them—a logic that is consistent with broader political developments that have imposed a culture of “management through measurement” on virtually all aspects of the delivery of health care with a resultant emphasis on efficiency.30 The wait times problem in the ED was articulated by participants as being the result of limited resources, and specifically, lack of beds. And underlying the lack of bed space is the problem of patients who pose barriers to efficient care by taking up an expensive acute care bed and “consuming time.” As one GIM resident noted during an observation, “There’s nothing we can do for these patients, it’s a bed issue.”
Participants noted that the emphasis on speedy admission meant that many failure-to-cope patients end up in GIM regardless of whether GIM could best offer the kind of care that they require. Physicians were often candid that these patients may require support and services that they are not able to provide within the parameters of their specialized professional capacity:
Partly because of the new performance targets … these patients just need to be admitted to hospital pending placement. It’s probably not the best place for them: they’re taking up an acute care bed, but we don’t have any other infrastructure available to us. [Senior ED physician, emphasis ours]
Interestingly, some GIM physicians acknowledged that failure to copes often do have an underlying medical condition that led to their admission, but the impetus for speedy admission means that these conditions are oftentimes not recognized in the ED:
Often I think it’s come up, you know, there are eventual medical things that are found to explain patients’ deterioration that weren’t readily apparent in the Emergency Department and just take some time to present themselves. [Senior ED physician, emphasis ours]
Although we observed many examples of effective collaboration between ED and GIM doctors, it seemed that failure-to-cope patients—and the push to admit them to GIM, perhaps without a concrete diagnosis—was demoralizing for the physicians in GIM:
And we already have 15 patients to see on an average night there, so one of those—which you always get one of those failure to copes a night, sometimes two or three a night—and they each [take] up 30 to 45 minutes to deal with, and it’s not really medicine, it’s you’re being, like, a glorified secretary, almost, which is not really the job of the consultant, that’s the job of the Emergency doctor to decide on a patient’s disposition, and when they rush it, it creates more work upstream. [GIM resident]
We observed that the Ontario wait times policy changes that formed the context of our study are having unplanned effects on the education of the trainees involved in the consultation process at the study site. Our study provides an account of how the goals of efficiency permeate physician consciousness, refocusing the medical gaze, restructuring social relations between physicians, and ultimately leading to profound changes not only in how residents and trainees are taught but also in what they are taught. Our data indicate a shift in priorities from teaching and learning good clinical care and assessment to meeting organizational performance measures. This created tension and conflict during consults between ED and GIM physicians, while participants’ medical gaze was refocused on the “next patient waiting” rather than on the patient currently receiving care.
As Hafferty15 observes, “the process of learning to differentiate between what is ‘important’ and what is ‘not important’ within the life-world of medicine is at the very heart of learning to become a doctor.” In examining the learning and modeling of intraprofessional collaboration between the ED and GIM departments of a major academic trauma hospital in Ontario, we found that government policies aimed at reducing ED wait times are having a significant impact on the training of medical students and junior doctors at the study site. The pressure to reduce wait times meant fewer opportunities for teaching, resulting in medical staff both explicitly and implicitly teaching trainees that efficiency is paramount.
This emphasis on efficiency was exemplified by the use of the informal description “failure to cope” as a medical diagnosis, despite the fact that it confers no medical information about the patient and is not recognized as a diagnosis in the medical literature. In addition, use of the term “failure to cope” implies that the patient has somehow failed, and may be stigmatizing. Being labeled as a failure to cope may alter the way these patients are perceived and may mask stress and conflict at an institutional level. Observations during shadowing and interviews all suggested that these sorts of patients very regularly present in the ED, and their care has become part of the daily responsibilities of GIM doctors. The working use of the term “failure to cope” advances the accomplishment of performance targets to improve efficiency to the detriment of clinical care and intraprofessional collaboration.
There has long been debate in both social science and health services research about how to properly describe patients, often with a particular focus on how these definitions inform our understanding of the proper relationship between patient and physician.31 The medical gaze has been deconstructed for decades by medical sociologists, anthropologists, and critical theorists (Atkinson,31 Becker,32 Sinclair,33 Foucault,34 and Frank,35 to name but a few) who have examined the impact of medical culture on how patients are described. These perspectives have allowed us to recognize that the language we use to describe patients is not just a matter of semantics.
Language confers meaning, and each of the terms used to describe patients is historically deep, as well as salient in the present. In addition to the various terms used to describe patients in formal, official capacities, there are also informal terms that circulate unofficially amongst caregivers and administrators. When reducing ED wait times became a government priority in Ontario, for example, certain patients became known as bed blockers. This term refers to those complex, often elderly patients with high comorbidities and lack of community support who could not be treated quickly and released. The current focus on efficiency and accountability has also led to patients being described in terms that suggest they are the source of the problem despite underlying systemic issues: frequent fliers, a term for patients who seek care at the hospital often, may be motivated by system inefficiencies; bed blockers, the name for patients who cannot be treated and discharged quickly, emerged as a result of bed shortages, which prompted the need for shorter lengths of stay; and failure to copes, a label for patients with “social” needs, could be a result of poor health planning for an aging population. Labeling patients this way suggests that the patients present some sort of problem that the health care system must overcome. And, more important, the patients become a problem for the individual clinical team rather than a focus of care. These policies and resultant discourses shift the clinical focus away from the patient and toward the achievement of “system” efficiencies.
We also observed that the emphasis on efficiency meant that more patients were transferred to GIM from the ED following fewer diagnostic tests, meaning that more work was pushed onto GIM doctors. This caused increased tension between ED and GIM doctors, further reducing opportunities for trainees to observe good, collaborative consultation processes between these specialties. These findings, as well as explicit statements by staff physicians about teaching efficiency—sometimes at the expense of other aspects of medical training—suggest that the hidden curriculum of efficiency is barely hidden at all.
Finally, the introduction of a CCL nurse, whose job was to ensure that patients were seen within the specific time periods set by the administration, dramatically worsened rather than improved participants’ perceptions of collaboration between physicians and nurses. As has been noted extensively elsewhere, traditional hierarchies between physicians and nurses often place nurses in a disadvantaged position in hospital settings.36 The CCL role exacerbated these professional tensions and refocused the nursing gaze to achieving system goals rather than patient care in a manner that did not allow for good teamwork to be modeled or learned between residents and nurses.
Our study focused on intraprofessional collaboration between physicians, and therefore we did not include the perspectives of other team members who are involved in the delivery of care. Future studies might explore the extent to which our findings are relevant for other health care professionals working in similar environments. In addition, only one researcher collected data during the observation stage, which introduces the possibility of bias. To mitigate this risk, our team undertook a rigorously reflexive approach to data collection that was achieved through group deliberation with team members who included ED and GIM physicians as well as social scientists.
Our study provides an empirical example of how a policy introduced to reduce system inefficiencies (in this instance, a strategy to reduce ED wait times) had unintended implications for medical education, and thus for the care that medical trainees will ultimately provide to the public. Through the hidden curriculum of efficiency, trainees at the study site were learning that knowing how to deflect patients elsewhere is an important component of good medical practice. Policy makers should consider the potential for policies that affect medical practice to also influence medical education through the hidden curriculum, and the impact that the hidden curriculum can ultimately have on patient care.
Acknowledgments: The authors would like to thank Dorothy Smith for her comments on an early stage of this analysis.