opinion

Much must happen for team-based care to succeed

A message to all physicians from Steven J. Stack, MD, chair of the AMA Board of Trustees, on the role of team building in the future delivery of health care.

By Steven J. Stack, MD , an emergency medicine physician in Lexington, Ky., was chair of the AMA Board of Trustees during 2012-13. Posted Jan. 21, 2013.

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Team-based health care: the provision of health care services by a physician-led team of at least two health care professionals who work collaboratively with each other and the patient and family to accomplish shared goals within and across settings to achieve coordinated, high-quality, patient-centered care.” — Policy adopted by the AMA House of Delegates, November 2012.

I couldn't do my job if I didn't operate in a team environment. Emergency physicians, physician assistants, nurse practitioners, RNs, LPNs, patient care associates, patient advocates, social workers and mental health specialists, along with registration and administrative personnel, are my regular companions. Not to mention pharmacists, radiology teams, and our hospital's staff of physician specialists and technicians. We all have our roles to play, and we play them regularly in harmony.

Because of the variety and urgency of the cases we see, my team-based practice is the norm rather than the exception for an emergency department.

But emergency departments are not alone. These days, most physicians routinely call on a wide variety of expertise to care for patients. We are practicing medicine in a world where we have identified more than 13,600 different diagnoses for what may ail our patients. And where there are 4,000 medical and surgical procedures to remedy those problems, along with more than 6,000 drug options, to reduce suffering, extend lives and sometimes stop a disease altogether.

The physician plays a central and leading role in this complex system. No one, however, no matter how well-trained he or she is, can possibly know all the answers or individually do all the work required.

This complexity requires a systems-based approach to health care in which we have access to a wide variety of expertise, tools and other information. And we are moving in that direction. Even before passage of the Affordable Care Act, we began to see alternative care models like accountable care organizations and patient-centered medical homes offering the promise of better care for patients at lower overall cost. And in much-heralded places like Mayo Clinic, the Geisinger Health Center in Pennsylvania, and Intermountain Healthcare, we have examples of team medical practices that have been successful over many years.

A decade ago, the majority of physicians were independent, self-employed or practicing in small groups. Today, only about a quarter of doctors are in solo or small group practice. We commonly have become employees of integrated multispecialty physician practices, hospitals and health systems that offer the possibility for more support, improved life-work balance, and an opportunity to better serve our patients. There are trade-offs to these changes, certainly, but few would doubt or deny that they are well under way.

Even though physician-led, team-based medicine appears to be the way of the future, a lot must happen for it to succeed. And a lot of the change is going to be focused on physicians themselves.

Recently, an Institute of Medicine working group published an article in the Oct. 3, 2012, issue of The Journal of the American Medical Association concerning principles and values they consider key for successful interprofessional team-based care. That working group suggested that it would not be a simple transition. Just putting a group of highly trained people together around a table or in a patient care environment does not make a functioning health care team, just as putting 11 highly trained athletes on a field does not make a winning football team.

Shared responsibility without highly coordinated teamwork simply will not work well. As we continue this evolution in team-based care, sufficient time — and energy — must be allotted to training the teams to work together and to develop trust and recognition that each medical team member has unique skills and knowledge to help a patient. We must supplement and support this trust with open and timely communication — also a learned skill.

Each member of the team should practice to the extent, though not beyond, the scope of his or her training and expertise. Team-based care does not imply or justify that the type, duration and quality of the education and experience of individual professionals no longer matters. To the contrary, maximizing the contributions of each individual team member also requires recognition of the limitations of each team member.

We must also fully commit to collecting, sharing and analyzing data, so it can be leveraged to care for patients in the larger health care system beyond that which we personally deliver.

We all know of group situations where uncoordinated care has led to difficulties. One example is “handoffs” where responsibility for a hospitalized or discharged patient without adequate communication between the sending and receiving groups can result in near misses or avoidable adverse effects.

Experiences in situations like these have caused many physicians to feel that team care can be cumbersome and may even increase medical errors. They are right — if the groups are formed without the right training and thought involved.

Because of the challenges involved in developing a highly functioning, team-based approach to medical care, the AMA House of Delegates adopted a number of policies and principles regarding physician-led health care teams at its Interim meeting last November.

These included, among other elements, the basics of building any team: Defining mission, vision and values. Creating a set of accepted protocols. Developing accountability for care, quality improvement, efficiency and continuing education. Encouraging all team members to contribute to the full extent of their expertise and resources. Supporting and promoting communication to ensure efficient quality care.

And the principles include a mandate to focus the team on patient- and family-centered care; to make the patient and the patient's family or caregivers, members of the team, and not just passive recipients. For many medical professionals, this last one may be the biggest challenge of all.

The new policies also include a particular charge to make care transitions more efficient, effective and transparent to patients and their families.

Teams are not static. Just as my emergency department engages different resources and health care professionals to treat a heart attack patient, a gunshot victim or a febrile neonate, the myriad teams throughout the health care system must be flexible and adaptive to patient needs and circumstances.

Teams, or any group of more than one, are not simple to manage, either.

Team-based health care will require skills that may not have been a big part of most physicians' medical education — something the AMA is working on as part of our effort to accelerate necessary changes in medical education.

Yet as we look toward the future, physician-led, team-based medical practice offers promise for our American health care system — a system that provides the most effective, efficient and cost-effective care for our growing patient population.

Steven J. Stack, MD , an emergency medicine physician in Lexington, Ky., was chair of the AMA Board of Trustees during 2012-13.

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External links

“Challenges at the Intersection of Team-Based and Patient-Centered Health Care: Insights From an IOM Working Group,” The Journal of the American Medical Association, Oct. 3, 2012 (link)

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