Medicine is clearly moving toward being a true team sport. Many of the proposed innovations in care delivery and payment depend on a collaborative approach, with individuals from multiple health professions playing a role. Perhaps the clearest example is the patient-centered medical home. Which all sounds great, until you start to ask different people what they mean by a “team.” Many physicians have a, well, physician-centric concept of a team, where the doctor serves as “quarterback” or “captain.” And while teams generally need leadership, you can imagine that a nurse, social worker, or pharmacist might have a less enthusiastic embrace of a team where she or he can, by definition, never be the leader. It’s not that physicians are trying to be uncollaborative. However, medicine has traditionally been structured hierarchically (e.g., doctors write “orders,” not “requests”). And this is reinforced throughout the training not only of doctors, but other health professionals as well.
To move toward a truly comprehensive, collaborative team approach, this approach needs to be embedded into the education of all potential team members, right from the beginning. By the time medical and nursing students have completed their four years of school, patterns of thought and behavior – cultural constructs – are already developed. This is why there has been an increased interest in interprofessional education, defined by the WHO as occurring when “students from two or more professional learn about, from, and with each other to enable effective collaboration and improve health outcomes.” MCW’s Community Medical Education Program is exploring the possibility of incorporating interprofessional education into the curricula at the regional campuses, in conjunction with the other health professional schools in those communities.
Dr. Melanie Dreher, Dean of the Rush University School of Nursing, recently gave a presentation sponsored by the CMEP on interprofessional education. She noted some of the dominant cultural constructs about medicine as a hierarchy that need to be revised, and the potential for interprofessional education to do so. I’ll call out two. The first is what I mentioned above, the idea of a team revolving around a single leader (typically a physician). She offered the counterexample of situational leadership, where leadership of the team is flexible depending on the issue being addressed. For example, if the issue is one of polypharmacy, then a pharmacist might assume the role of leader; if it is one of support services, perhaps the social worker. An analog is the Orpheus Chamber Orchestra, a group in which the role of conductor is shared and rotated among all members, depending on the piece to be performed. As they see it, it is not the conductor who is the center, nor even the musicians – it is the audience. The other cultural construct is that of how we measure contributions to the team. It can’t be by RVUs generated, or papers published, or referrals received, which ignores equally important roles played by many of the members. Dr. Dreher offered the basketball example of Shane Battier of the Miami Heat, whom Michael Lewis referred to as the “no stat All-Star.” He is considered one of the best defensive players in the league. But he has few points, rebounds, or assists –the conventional measures of success – and is therefore undervalued compared with high scorers, although statistics suggest that there is a stronger correlation between Battier’s playing time and the team’s record.
A true team approach means we need to fully utilize and recognize the unique knowledge, talents, and approaches provided by every member of that team. Engendering that attitude, and teaching the actual skills of teamwork (which are separate from the skills inherent in being a doctor, nurse, or pharmacist) means we need to break down the silos in which health professionals learn. It’s not a terribly new concept: when I was in medical school, the physician assistant students and medical students took several of their preclinical classes, such as anatomy, together. It fostered a sense of collegiality and mutual understanding. But is has not become widespread. As we evolve toward a more collaborative model of health care, the way we educate health professionals must adapt as well.