“The time has come,” the Walrus said,
“To talk of many things:
Of shoes—and ships—and sealing-wax—
Of cabbages—and kings—”
—Through the Looking Glass, Lewis Carroll
“Team approach” has become a popular medical buzzword, and in our mind's eye we easily envision a perfect interdisciplinary alliance of healthcare experts with diverse expertise.
By contrast, traditional medical teams often seem more like restrictive closed shops. In its conventional application, the word team lacks nuance—it simply denotes the involvement of two or more people in some aspect of a patient's care. Such teams are often composed of interchangeable cogs, frequently from a single subspecialty, created for administrative and clinical efficiencies in accomplishing a singular task. That is not always a problem; for many tasks, there really is a best way. A wide variation in skill, experience, philosophy, or training is counterproductive on a venipuncture team. Diversity of thought is detrimental when adherence to evidence-based protocols is essential; everyone on a stroke team should follow the same thrombolytic rules.
How, then, should we design an ideal healthcare team? Should membership be multidisciplinary to garner diverse perspectives and fresh insights, or should members be interchangeable clones to guarantee consistency? In reality, medical teams exist for a variety of reasons, and we must know a team's objectives before deciding on its optimal composition. Clear definitions of purpose are essential; vague definitions create confusion and disruption.
“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.” “The question is,” said Alice, “whether you can make words mean so many different things.”
—Through the Looking Glass, Lewis Carroll
The research study in this month's JAAPA (“Primary care provider type: Are there differences in patients' intermediate diabetes outcomes?” on page 36) takes an important look at one team approach to the outpatient management of diabetes. The composition of the teams (physicians, PAs, NPs) suggests a multidisciplinary approach. In reality, though, clinicians functioned asynchronously as interchangeable providers of equal ability. The result? Intermediate markers of quality of care (A1C, systolic BP, and lipid control) were the same for physician plus PA teams, for physician-only care, and for PA-only care. This is not surprising to anyone familiar with the PA profession, but it is important confirmation of the essential role of the PA profession in optimizing access to superb care for all Americans.
A caveat: the intermediate markers measured in the study are important, but they are not the end-all of diabetes care. Patient care is a humanistic endeavor, and the statistical analysis of data sets can never capture the caring part of medicine. Adding a new medication might bring an A1C from 7.5% to 7% and check off a box in the gradebook of “reaching goal”; gaining patient trust while overcoming educational and psychosocial barriers to bring an A1C from 14% to 10% is a far greater accomplishment, but will never show up in the box score of “patients reaching goal.” Preventing a patient's death from hypoglycemia by allowing A1C to drift upward from 6.9% to 7.5% is a therapeutic victory of monumental effect, but it will be listed in the failure column if A1C is the sole marker of quality of diabetes care.
Despite the ubiquitous use of statistical data as a surrogate for quality of care, we must remember that clinical excellence often is the result of the intangible components of a therapeutic relationship: “Not everything that can be counted counts, and not everything that counts can be counted.”1
As we create newer systems of team-based care and try to measure their value, we should not lose sight of the importance of a primary clinician who is recognized by the patient. Some things in medicine cannot be delegated. Relationship-centered healthcare, the trademark of PA care, is where the magic of medical care takes place. Improving patient health, the ultimate purpose of what we do, usually begins when a trusted provider asks a patient, “What can WE do better?” “We”—the alliance of a patient and a devoted provider—is still the most important medical team ever invented.