In the early 1990s, at the outset of my career as a psychologist in medical settings, I spent 5 years at a physical medicine rehabilitation hospital on what I was sure was a team of perennial all-stars. During our weekly clinical meetings, daily curbside dialogues in the hallways and cafeteria, and co-care in the PT gym and patients’ rooms, I always marveled at the competence, youthful confidence, and innumerable skills of the doggedly optimistic physical and occupational therapists, canny speech therapists, hardy nurses, and street-smart social workers on my assigned squad. At the head of this team was usually a gray-haired, white-coated physiatrist, wizened and patient, offering subtle guidance to team members but generally allowing us to practice our crafts. Not that harmony always reigned. We would have table-pounding debates about treatment plans. Rivalries simmered about who best evaluated cognition or ambulatory status. But the team worked proudly and effectively and patients usually thrived.
I’ve been waxing nostalgic recently about those years because of family medicine’s ostensible move toward team-based care. The patient-centered medical home (PCMH) is intended to be a collaborative, integrated, multidisciplinary place where family physicians work shoulder to shoulder with behaviorists, pharmacists, case managers, social workers, medical assistants, and administrators to deliver improved, cost-effective, chronic disease management. But the culture of family medicine, in my opinion, is not yet team driven. What is second nature in physical medicine rehab is of necessity first nature for us—a new set of spiffy dress-up clothes without the well-worn comfort of habitual garb. I think there is much we can learn from rehab medicine’s decades-long experience with teams:
Multidisciplinary isn’t interdisciplinary. An oft-cited truism in the field of integrating behavioral health services into primary care is that “co-location isn’t integration”—that is, proximity by itself doesn’t lead diverse clinicians to work in tandem toward better patient outcomes. I think this truism extends to team-based care in general. A multidisciplinary PCMH just connotes different disciplines under the same roof, which are working on their own respective and possibly divergent goals. Rehab was distinctly interdisciplinary—different disciplines working on commonly agreed upon goals. I believe that the PCMH likewise needs to be interdisciplinary to best blend the talents and skills of multiple specialists striving together. That means, like rehab, there needs to be processes in place for ongoing team communication and decision making. (An EHR alone won’t suffice.) That means somehow creating team meeting times out of the hectic primary care work flow.
Interdisciplinary shouldn’t become “trans-disciplinary.” In my years in brain injury rehab, we experimented with “trans-disciplinary” care—clinicians from different disciplines taking on aspects of each other’s jobs to reinforce one another’s interventions to better achieve clinical goals. For instance, the physical therapist might counsel the stroke patient about his/her depression. I might reinforce ambulation techniques with that patient when he/she walked back and forth to my office. While this model seemed promising in theory, in practice it led to a diffusion of team member roles that exacerbated underlying rivalries. It seemed we all needed some protected territory we could stake out as our own.
While the integrated PCMH certainly requires some delegating of responsibilities, eg, having the medical assistants and not the behaviorists administer a depression screening instrument, we ought to maintain the kind of role distinctions that allows us to protect our professional identities (and egos). I like the interdisciplinary spirit embodied in the phrase, “All for one and one for all.” I eschew the trans-disciplinary credo of “All are one.”
Leadership is a skill set. Past STFM president Perry Dickinson, MD, and his colleagues at the University of Colorado-Denver developed well-conceived competencies for family physicians to lead the interdisciplinary team. They include setting expectations for performance and change, sharing information, and being receptive to others’ ideas and managing interpersonal issues. But these will remain little more than abstract and somewhat daunting concepts to family medicine residents unless we give them practical real-life experiences. As part of their training to become physiatrists, physical medicine and rehabilitation (PM&R) residents spend abundant time observing their attending physicians leading team meetings. Later, those residents lead the teams themselves. They come to know well the nuances of the various specialties around the table, as well as the ebb and flow of team dynamics. Family physicians need that kind of socialization to step into the team leadership role.
Follow which leader? The 2010 “Joint Principles for the Medical Education of Physicians as Preparation for Practice in the PCMH” calls for “physician-directed medical practice,” ie, physicians as leaders of the clinical team. This was always the case in rehab as well. But others have questioned whether physicians’ needs always take the lead. In a workshop at the 2012 Collaborative Family Healthcare Association conference, Jeri Hepworth, PhD, immediate past president of STFM, and Susan McDaniel, PhD, of the University of Rochester Departments of Family Medicine and Psychiatry suggested that team leadership can be handled in more egalitarian fashion by rotating leadership among team members. They contended that this flattens team hierarchy and ultimately leads to more trusting, cohesive, and coordinated team care.
Bring patients and family members on board. Because rehab medicine is to a large degree about transferring skills to enable patients to better function in their home environments, PM&R teams work intensively with patients and their family members to provide them with education, hands-on experience, and emotional support. If patients and family members aren’t quite full-fledged clinical team members, then they are fully deputized partners in care. Family medicine’s approach to teams needs to likewise embrace patients and family members. This goes beyond “patient activation” or reflexively documenting patients’ goals for medical visits. This means including patients and family members in team deliberations through regular communication and feedback loops. It also means involving patients and family members in the running of our PCMH practices by asking them to serve on advisory boards and volunteering to assist us with our quality improvement projects. The measured performances of rehab teams rest firmly on the quality of the lives of patients and family members. The performances of family medicine teams—interdisciplinary, prevention focused, functionally oriented—need to as well.
Barry J. Jacobs, PsyD, is the director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA, and a CFHA board member. He is the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Loved Ones While Helping an Aging Parent.
This is the fourth in a series of collaborative blog posts between the Collaborative Family Healthcare Association and the Society of Teachers of Family Medicine.