The Big Picture: Why Health Professionals Are Often Poor Team Players—And How to Change It
Lately I have been suggesting to whoever is in earshot that each of us should be doing our best to develop a profound sense of professional inadequacy in all health practitioners.
Strange goal, one might think. Who would choose a practitioner who feels fundamentally insecure about his or her ability to assist patients and clients?
Let me frame this with a different question. What if all health professionals feel uncomfortable in their practices unless they are securely embedded in networks of teams who complement what any can offer alone?
The benefits of teamwork
These considerations began stirring in me through participation in various projects related to a national movement called “interprofessional education” or “interprofessional care.” This effort to enhance “team care” is presently being seeded by millions from the US government and large foundations.
Jarring professionals with the shock of their professional inadequacy fits the urgency of our situation. We have huge barriers to providing optimal healthcare. These demand more transformation than is captured by merely stating that a practitioner must be competent to make appropriate referrals when necessary.
Health creation marches to a different drummer than “when necessary.”
The remedial movement for team care faces one particularly horrendous obstacle: the US payment system. Practitioners get paid more the more they, personally, do. If they refer, they may (as practitioners say) “lose” a patient. This economic loss is felt even if such a patient gains health through the referral or teamwork with another.
Our history of directing rivers of payment and reimbursement toward self-centered, entrepreneurial professionals—whether massage therapists or hospital subspecialists—erodes deep gullies between caregivers. Financial spreadsheets benefit from deciding that patients need one’s own services then holding on to them as long as possible.
For consumers, it is never pretty to think that financial incentives may be shadow algorithms in our practitioner’s treatment choices, but it happens and it is as true in community practices as in hospitals and health systems.
The costs of isolation
The ugly results were captured in two Institute of Medicine (IOM) reports a decade ago. To Err Is Human and Crossing the Quality Chasm concluded that over 100,000 lives are unnecessarily lost each year through medical error. Disrespect between members of different types of professionals and poor team care were identified as key factors.
The need for change was underscored again in the 2011 Blueprint for Pain in America, also from the IOM. The report recommends a multidisciplinary, integrated approach to pain care—no single profession has the tools to deal with what observers are increasingly calling an epidemic of chronic pain.
That integrative medicine and health are bringing heretofore excluded professions into the mix is another reason for affirmative engagement with team care. The potential contributions of acupuncturists, chiropractors, massage therapists, yoga therapists, naturopathic doctors, and others are part of the mix.
The good news is that the 2010 Affordable Care Act (aka “Obamacare”) and recent activity of the US Health Resources Services Administration (HRSA) are fostering better respect for teams. The federal agency’s administrator, Mary Wakefield, PhD, RN, kicked off the announcement of Core Competencies for Interprofessional Collaborative Practices in May 2011. This historic document was jointly developed and endorsed by the Interprofessional Education Collaborative, a group consisting of national academic organizations representing medicine, nursing, public health, pharmacy, osteopathy, and dentistry.
The agency subsequently announced a $4 million commitment to creating the National Center for Interprofessional Practice and Education at the University of Minnesota. A group of major foundations, led by the Josiah Macy Junior Foundation, added $8.5 million to the five-year, $12.5-million project.
The Macy Foundation’s CEO, George Thibault, MD, is widely viewed as the energizer bunny for this activity. Thibault has publicly committed to implanting interprofessional education in US medical education. Macy Foundation-backed summits have explored links between interprofessional education and team care.
The Macy Foundation supports interprofessional projects at multiple universities as well as anchoring the Global Forum on Innovation in Health Professional Education, also via the IOM. This multiyear initiative convenes leaders of virtually all health professions. Team care is a core theme.
Behind these actions percolates awareness that payment schemes in the emerging patient-centered medical homes and so-called accountable care organizations break the isolating spiral of fee-for-service payment that stimulates professional self-interest. Thanks to payment benefits and penalties in the Affordable Care Act, for instance, a hospital’s rough “discharge” is becoming a “handoff” or a “transition” to other providers. Teamwork is a central concept of a medical home.
Implications for CAM practitioners
Whether this movement will include practitioners favored by users of complementary, alternative, and integrative therapies is yet unknown. Participation may be a key. The Academic Consortium for Complementary and Alternative Health Care, for instance, chose to join the Global Forum noted above, thus putting diverse integrative health disciplines at the table.
This participation (with which I have been involved) has led to a perception that major healthcare disciplines need to “widen the circle,” as Thibault put it, of those considered part of future teams. The organization has also sought direct involvement of these integrative health disciplines with the National Center, thus far without success.
The potential for leadership of integrative medicine in this movement for team care was recently announced. A new specialty board for integrative MDs and osteopaths adopted a fundamentally interprofessional definition of integrative medicine. Competence is defined not merely by the ability to integrate various therapies; rather they must be able to integrate “health professionals and disciplines.” The language deserves adoption by all health disciplines. The MD-led integrative medicine field, however, has not yet made participation in this broader interprofessional education movement a priority.
Cynics have plenty of ammunition. The Canadian government, for instance, invested $20 million 10 years ago in successfully promoting team care across Canada’s provinces. A similar US commitment, given the size of the economies, would be $200-million. This is 50 times size of the $4-million noted earlier.
Others may point out that team care is easier when practitioners are employed rather than dependent on fees for their own services. The Mayo Clinic and staff model of health maintenance organizations prove this theory. It appears that single-payer systems, like the Canadian, also promote appropriate use of teams.
As noted, these huge structural challenges are partially, if inadequately, addressed under the Affordable Care Act. The change needed is systemic. Economic incentives as well as philosophic changes in health professionals must be addressed.
For the latter, we can start with instilling an awareness of the inadequacy of individual practitioners. This should be paired with a vision of wholeness through robust relationships in their communities to a multidisciplinary group of mutually-respectful, curious, and trusting professionals.
John Weeks is the editor of “The Integrator Blog News and Reports” (theintegratorblog.com), a leadership-oriented news, networking, and organizing journal for the integrative medicine community, and a columnist for Integrative Medicine: A Clinician’s Journal.