Module 13: Health Care Teams
Upon completion of this module, the resident should be able to:
- Identify and describe different approaches to team-based health care.
- Describe the background to and advantages of team-based health care.
- Identify both discipline-based and group ethical obligations in team-based health care.
- Assess your role and the roles of others within team-based health care.
Module: 13 / Decision Making in the Context of Health Care Teams
Health care—especially the care provided in such institutional contexts as hospitals and nursing homes—is increasingly complex and specialized. Specialization makes possible in-depth knowledge of the phenomena of human health and disease and exquisitely refined technical skills for diagnosing and treating disease. And yet specialization can also promote a compartmentalized, fragmented view of patients and their problems. This paradox is but one of the drivers of team-based health care, which has emerged with the realization that no one individual, discipline or profession can meet the challenges and the multiple needs of patients. Comprehensive, therapeutically efficacious care demands that individuals of different professions pool their knowledge and skill in a collaborative, coordinated way in order to achieve the goals of medicine—cure, restoration of function, comfort and care.
Various studies have documented the largely positive impact of team-based care on patient outcomes and resource utilization. In one study, upon admission to an acute care hospital, more than 1,000 patients were randomly assigned to one of two groups, with approximately half receiving interdisciplinary team-based care (i.e., the intervention group) and the other half receiving traditional care (i.e., the control group). The membership of each team included physicians, nurse practitioners, a pharmacist, nutritionist, and a social worker. For the intervention group, compared with the control group, there were shorter mean lengths of stay and lower mean total charges. Studies of patients with stroke, diabetes, pain, chronic fatigue syndrome, and mental illness have also documented the relationship between team-based care and higher patient satisfaction.
In their text, Supportive Care for the Urology Patient (Oxford University Press, 2005), Currow and Norman offer a useful typology of team-based care, arguing that there are three basic types of team: unidisciplinary, multidisciplinary, and interdisciplinary teams.
Unidisciplinary teams: These teams—for example, a group of urologists—are comprised of individuals from the same discipline with the resulting advantage that the team members have a common frame of reference and speak the same language. Solutions to the problems presented to the team are usually decided by the team leader (often selected on the basis of rank); such solutions may have the virtues of depth but lack that of breadth.
Multidisciplinary teams: These teams draw their members from multiple disciplines. A good example would be a group comprised of an urologist, an advance nurse practitioner, a social worker, a chaplain, and a nutritionist. Thus, multiple perspectives are brought to bear on the problems presented to the team for solution and the solution, itself, tends to broadly framed. However, the differences in the languages spoken by the members of the team, plus the absence of a concerted effort to integrate perspectives, may complicate the process of developing effective solutions. Each team member independently contributes his or her expertise to the solution of the patient’s problems and thus tends to work in parallel to other team members, rather than in orchestrated concert with each other. The principal means of communication among the team members may be the medical record, rather than face-to-face encounters and meetings. Leadership tends to be exercised by the physician.
Interdisciplinary teams: These teams also draw their members from multiple disciplines but with the aim of integrating their different perspectives and recommendations into a coherent plan of care for the patient. To that end, the team members work interdependently and collaboratively to formulate solutions of both depth and breadth. To be sure, each member, depending on his/her specialty and discipline, has specific tasks but each is tied to achieving the goals of a group-developed and shared plan of care. Indeed, each member must consider the contributions of every other team member to ensure integrated management of the patient’s problems. Lines of communication between and among team members are continuously open, maintained, and used. Leadership may be highly fluid and changing, determined on an ad hoc basis, depending upon the nature of the patient’s problem.
Hall and Weaver have identified a fourth type of team-based work and are, the transdisciplinary team, in which the roles of team members are blurred and their professional functions tend to blend together or overlap. Each team member must also acquire a degree of familiarity and facility with the knowledge and skill base of other members. (Hall P and Weaver L. Interdisciplinary education and teamwork: a long and winding road. Medical Education. 2001; 35:867-875.)
Activities of a team:
- Defining—that is, diagnosing—the patient’s problem; discussing, negotiating, formulating the goals of care
- Gathering information about the problem and framing the problem (i.e., from the perspective of each discipline represented in the team)
- Developing an expansive view of the problem for this patient
- Developing potential solutions or management plans
- Evaluating potential solutions
- Summarizing the plan of care and agreeing on the distribution of tasks among members
With respect to the hallmarks of an effective interdisciplinary health care team, every member will strive to develop
- Awareness of differences and similarities in professional skills and education
- Awareness of how these differences and similarities affect collaboration in patient care
- Awareness of the dynamics inherent in every interpersonal, group situation
- Willingness to communicate and negotiate in order to work through differences and accomplish goals
Previously, specialization was identified as a prime motivator in the formation of health care teams. There is another impetus to developing and sustaining well-functioning health care teams and that is the problem of preventable medical errors—for which poor communication between and among health care givers is the most common cause. Preventable medical errors cause more deaths every year than breast cancer, accidents or drownings: indeed according to the Institute of Medicine’s 1999 landmark report, To Err Is Human, an estimated 98,000 Americans die each year because of medical errors at an economic and financial cost to the nation of approximately $29 billion. As the report stresses, such deadly errors are rarely the result of individual ignorance or ineptitude: they are, rather, the product of “system failures,” especially failures in communication between and among caregivers. The value and potential of teamwork skills and training have been extensively studied in the military and in commercial aviation and some of the lessons have been applied in health care. But much remains to be done.
Several somewhat entrenched features of the culture of contemporary medicine and health care present barriers to the formation and operation of effective health care teams—especially interdisciplinary health care teams. One is hierarchical structure: in some organizations and institutions, this traditional mode of organizing individuals and their work remains in force. Another is traditional physician-nurse conflict. A third feature is pervasive and it is the lack of any substantive interdisciplinary education. Physicians, nurses and advance practice nurses, social workers, pharmacists, nutritionists, and others: all are educated and trained in their respective “silos” and are assessed against standards or criteria that rarely, if ever, underscore the importance of communicating across disciplines, of collaboration, or of mutual understanding and respect.
Each member of a health care team has special obligations or duties—toward the patient, the family, the institution, and society at large. These ethical imperatives, which differ from team member to team member, are framed by the care-giver’s profession, scope of practice, and individual expertise. It is critical to acknowledge as well, however, that despite their differing professions and areas of expertise, team members work and collaborate in the service of several over-arching, well known, and unifying ethical precepts: (1) that diagnostic and treatment decisions are made to maximize benefit to the patient and to minimize harm, (2) that patients, their families or surrogates are participants in the process of shared decision making and that their preferences, values and needs are to be respected and tended to, and (3) that respectful, professional conduct within the team is crucial to the achievement of the first and second precepts.
The following are suggested questions for analysis, reflection, and discussion, either on your own or in the context of a group.
- What is the primary role and expertise of a practitioner in your discipline? Is there anything that is within the domain of your profession alone?
- Do you possess skills that are not necessarily associated with your discipline but that would be useful in a team?
- Are there areas of potential overlap among the skills, backgrounds, knowledge, and values of the other care givers on the team?
- Are there roles that you believe to be within the domain of a specific other profession/discipline? Is overlap between/among roles and functions good?
- What are the ingredients of a successful team? What are the advantages of providing health care as a team? What factors interfere with the effective functioning of the team? What is required of every individual on the team in order to work collaboratively with every other individual on the team?
- How do your personal attitudes, values, and beliefs—how does your cultural background—affect your working relationship with other members of the health care team?
The website for Washington University’s Center for Health Sciences Interprofessional Education can be found at: http://interprofessional.washington.edu/.
An interesting report on an academic health sciences center task force on interdisciplinary team development can be found at: http://www.ahc.umn.edu/tf/ihtd.html.
A literature review of interdisciplinary collaboration and teams can be found at: http://www.ahec.hawaii.edu/literature/hall.pdf.
The challenges of interprofessional/interdisciplinary education are explored in an article found at: http://www.health-disciplines.ubc.ca/chd_site_files/publications/InterprofEduc&Collab.pdf.
A brief on-line course on interdisciplinary health care teams can be found at: http://dcahec.gwumc.edu/education/session3/index.html; another is available at: http://www.interprofessionalhealth.wisc.edu/InterdisciplinaryModule.pdf. An overview of interdisciplinary health care teams can be found at: http://www.med.unc.edu/epic/module4/m4to.htm.