Tag Archives: science

The Joy (and Jostling) of Team-Based Care

Barry J. Jacobs, PsyD

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.

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Aligning Our Efforts to Transform the System

Robert Cushman, MD

As a longtime member of the Society of Teachers of Family Medicine (STFM) and the incoming president of the Collaborative Family Healthcare Association (CFHA), I am both excited and a bit anxious about taking on this role at this time, because we are truly at a critical juncture. As health care providers and educators, we offer clinical services in a “system” that is about to either continue making important strides forward toward becoming a true system achieving meaningful outcomes or to slip backward into the free-for-all chaos that has complicated delivering good, patient-centered care for decades. We need to work together as members of STFM and CFHA to navigate through these twists and turns, or plow through some obstacles, so that we, our trainees, and our patients and communities, come out in better shape on the far end.

I want to share one of the “clinical pearls” I learned in my residency, which has served me well as a “compass,” and which I have quoted (with attribution!) many times to my own trainees as I precept them in the hospital and the office. I offer it now because it is applicable beyond the direct patient care process. I can still hear Tom Campbell saying, “When you’re stuck, expand the system.” He of course meant to explore more into the patient’s family and community context, gathering the perspective of some of those folks that make up that social network or enlisting their assistance in changing parts of that context to achieve change for the patient. He also meant to ask for input and additional, new, and different perspectives and suggestions from one’s professional colleagues, both diagnostically and for interventions. This approach has proved hugely valuable to me, repeatedly. And I think the current emphasis on team-based care is a result of a collective recognition that this systemic approach is valuable and more effective than “going it alone.”

I want to challenge us all to continue to “expand the system” in three ways. I want us to expand our concept of teams, to expand our measurements of what we’re doing, and to expand our reach. Let me elaborate briefly on each of these.

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