Team spirit

Teamwork seems to be all the rage right now in health care. Indeed, it’s one of the key elements in the concept of the patient-centered medical home – multidisciplinary teams of physicians, nurse practitioners and other professionals each contributing their skills and united in caring for the patient.

Intuitively it makes sense. No one group, or profession, can do it all alone. There’s a lot to be gained from the expertise of pharmacists, nurses, therapists, social workers and so on that is to the benefit of patients.

I’m always a little bemused when the discussion turns to health care teams. Often the implication is that this is something brand-new, bold and different. The reality is that rural health care has been doing the team thing for many years, and they’ve been pretty darn successful at it. Back when the University of Minnesota offered its (now defunct) Rural Health School program for students in the health care professions, I once interviewed a group of participants who were completing their Rural Health School rotation in Willmar. One of the first things they all commented on was the teamwork they saw among local providers and the level of interdisciplinary participation that was fostered and encouraged.

In some ways, rural providers have been forced into effective teamwork as a matter of sheer survival. They don’t have the resources to draw on that their colleagues in an urban center might have. They’ve had to learn to come up with their own solutions and be more reliant on local partners to help them. Failing to recognize or respect the necessity of teamwork is to be hamstrung in the effort to deliver good care.

Rural providers seem to instinctively know this, even if they don’t articulate it in so many words. Functioning as a team isn’t automatic in health care, however, a point that struck home when I encountered this recent study in the August issue of Health Affairs journal. Simply put, health care professionals aren’t trained in ways that invite teamwork, the authors explain:

Team-based primary care offers the potential to dramatically improve the quality and efficiency of care, but its broader adoption is hindered by an education system that trains health professions in silos… Changes in professional cultures, organizational structures, clinical partnerships, admissions, accreditation and funding models will be required to support the expansion of collaborative education effectively.

It’s the direction in which we appear to be headed, at least in primary care. Some of the motivation obviously is to provide better care for patients. But as the health care system, and primary care in particular, comes under increasing strain, there’s also a need to do more with less and make limited resources stretch further. In other words, to respond in the way rural health providers have already learned to do.

And excuse me for wondering whether the rush toward “teamwork” won’t end up magnifying the inherent flaws in the team approach, to the detriment of patients.

Not everything about team care is peaches and cream. Just ask Stephen Wilkins, who blogs about doctor-patient communication at Mind the Gap. He recently tackled the concept of team care in the patient-centered medical home and concludes “there are a whole bunch of things wrong” with this focus. For patients who want their primary relationship to be with the doctor rather than a doctor or physician assistant, team care can be a hindrance, Wilkins wrote. More players involved can result in more opportunities for miscommunication and for things to go wrong, he points out.

And if you were to ask individual patients, many of them might have clear preferences for how they wish to be cared for, he wrote:

I have nothing against nurses, nurse practitioners or physician assistants. I just prefer to discuss my personal health with my physician of many years. Other people may be quite happy working with physician extenders. The point is it should be my choice who I see for care and not the choice of the physician, physician group, insurance company, government or anyone else.

I’d add a couple more potential issues. People in the health care professions can have strong, take-charge personalities that don’t necessarily serve them well when it comes to playing well with others. This can lead to teams that perhaps look unified on the surface but underneath are fractured with egos and dissent. On the other hand, when power is shared more equally it can mean that no one really has overall responsibility for directing the care of the patient.

When it’s done well, teamwork can enhance patient care. It doesn’t even have to be visible; some of the best teamwork takes place behind the scenes. Rural health care providers aren’t invariably better at this than everyone else, nor are urban and suburban providers invariably worse at it. Successes and failures can and do occur in both settings. But rural providers, on average, seem to have absorbed some of the lessons a little better. There’s a difference between being a team in name only and being a team with genuine esprit de corps. And this difference, although it can be elusive, is critical.

West Central Tribune photo by Rand Middleton

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